Below is the application for Rock Rapids Municipal Utilities Service. To apply for service, complete the application, have it signed by all adults over the age of 18, and bring the completed form into our office. Please refer to the Utilities’ general information for additional items needed.
NEW RESIDENTIAL ACCOUNT INFORMATION
CUSTOMERS NAME ACCOUNT NO. ____________
ADDRESS CREDIT REFERENCE _______
HOME TELEPHONE DEPOSIT RECEIPT NO. __________
CELL PHONE ELECTRIC ___________
CELL PHONE WATER __________
OWN HOME RENT GAS _________
IF RENTING, OWNERS’ NAME
TOTAL DEPOSIT PAID ___________
PERSONAL REFERENCE
CUSTOMER’S EMPLOYER
ADDRESS
CITY STATE ZIP
CUSTOMERS SOCIAL SECURITY NUMBER
SPOUSE/ROOMMATE #1- NAME
EMPLOYER
ADDRESS
CITY STATE ZIP
SOCIAL SECURITY NUMBER
ROOMMATE #2 - NAME
EMPLOYER
ADDRESS
CITY STATE ZIP
SOCIAL SECURITY NUMBER
Please list the last utility you have received service from.
NAME ADDRESS
CITY STATE ZIP
ADDRESS WHERE SERVICE WAS RECEIVED CITY STATE ZIP
OPTIONAL - - If there is a problem with a past due account balance at this residence and service may be discontinued, I would like to have the following person (agency) notified.
NAME
ADDRESS
CITY STATE ZIP
TELEPHONE RELATIONSHIP
I hereby apply for service in accordance with the Rock Rapids Municipal Utility's rules and regulations. I understand by signing this application I am jointly and severally liable for all charges incurred at this residence.
CUSTOMER’S SIGNATURE __________________________________DATE
CUSTOMER’S SIGNATURE __________________________________DATE
CUSTOMER’S SIGNATURE __________________________________DATE
Welcome to Rock Rapids Municipal Utilities
Your Locally Owned Utility Provider of
Natural Gas, Electricity, Water & Sewer in Rock Rapids, Iowa
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