Forms • McCook, NE • CivicEngage

Application for Utility Services

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APPLICATION FOR UTILITY SERVICE
Service Start Date:*
Service Address:*
If Rental Property: *We have the right to notify your landlord if your payment is delinquent.
Landlord Name:
Landlord Phone:
ACCOUNT HOLDER INFORMATION
PRIMARY ACCOUNT HOLDER:
Primary Name:*
SSN Last 4:*
Mailing Address:*
Phone:*
2nd Phone:
Employer:
Work Phone:
email Address:
Previous Address:
OTHER RESPONSIBLE PARTY:
ORP Name:
SSN Last 4:
Phone:
Employer:
Work Phone:
THIRD PARTY NOTIFY
If you wish to designate a "Third Party" to be notified in case of Disconnection of Service, please indicate below. It will be necessary for you to inform this person that he/she is your "Third Party".
Third Party Name:
Phone:
The undersigned Customer requests the City of McCook Utilities to furnish Water, Sewer, Trash Collection and Recycling. The Customer agrees to pay the required deposits, fees and rates as amended from time to time and filed with the City Council. Customer agrees that service will be furnished as required by City Ordinances and the Service Polices and Conditions of the McCook Utilities as amended from time to time and filed with the City Council. Customer agrees to notify the McCook Utilities when service is no longer desired.
SERVICES POLICIES AND CONDITIONS	Services Policies and Conditons
Electronic Signature:*

* indicates required fields.