Official Website of the City of Sturgis, SD - Utility Application and Agreement

*Applicant First Name

Applicant Middle Initial

*Applicant Last Name

Business Name if applicable

Business FEIN#

*Applicant Phone Number with Area Code

*Physical Address of Service

*Mailing Address (street/unit) for Billing

*City

*State/Province

*Postal Code

*Applicant Social Security Number

In addition to the Social Security # at least one additional form of government issued ID is required.

Applicant Driver's License Number and State of Issue

If no Drivers License - List Alternate Type of Official Government Issued ID

Include the issuing agency as well as the number

*Applicant Email Address

*Have You Ever Had Service With Us Before?

Yes

If Yes, provide the address and date.

*Enter a Name and Phone Number for an Emergency Contact

*Applicant's Employer Name, Address and Phone Number

If you are making application with another person please provide the following information:

Co-Applicant First and Last Name

Co-Applicant Social Security #

Co-Applicant Drivers License or other Government ID # and Description of Issuing Entity

Co-Applicant Phone Number with Area Code

*Do you Own or Rent at this Service Location?

Own

Rent

If You are Leasing at this Location, Provide the Date of the Lease and the Name of the Landlord

If you own or are buying please provide the closing date

Please read the following statements and check the box indicating that you have read, understand, and agree to comply with the statement.

*I understand that in the event of delinquency, fees will continue to accrue on your account as long as it is active even if it has been sent to collections.

I understand that in the event of delinquency, fees will continue to accrue on your account as long as it is active even if it has been sent to collections.

*I understand that my deposit will be applied to the final bill after service is terminated. I also understand that I am responsible for promptly contacting the City of Sturgis if the property is sold, if I move, or if there are any 3rd party charges that may affect this account.

I understand that my deposit will be applied to the final bill after service is terminated. I also understand that I am responsible for promptly contacting the City of Sturgis if the property is sold, if I move, or if there are any 3rd party charges that may affect this account.

*As a utility customer, I agree to comply with all MUB regulations and City ordinances and will provide access to the utility meters for reading and/or maintenance.

As a utility customer, I agree to comply with all MUB regulations and City ordinances and will provide access to the utility meters for reading and/or maintenance.

Providing the applicant and co-applicant names below constitute signatures. Additionally, by providing these signatures, the applicant(s) certify that the information provided on this form is true and accurate and the applicant(s) agree to be financially responsible for all utility bill charges including late fees, reconnect fees, etc., as long as the utility bill remains in the applicant's name.

*Primary Applicant Signature (type name)

Co-Applicant Signature (type name) if applicable

NOTE: A deposit will be required for all new accounts. Once you have submitted this application, please call the Utility Office at 605-347-4422 ext. 1 or come to the office located at 1040 Harley-Davidson to make arrangements for your deposit. Office hours are 7 AM to 6 PM Monday - Thursday. Your account will not activate until arrangements for your deposit are complete.

For Office Use Only:

Deposit Amount

Deposit Type

Cash

Cash

Credit Card

Credit Card

Check# _____________

Check# _____________

Receipt Number

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