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1. Applicant Information This section is complete This section is incomplete
2. Co-Applicant Information This section is complete This section is incomplete
3. Service Address This section is complete This section is incomplete
4. Service Application Type This section is complete This section is incomplete
5. Special Notes & Acknowledgments This section is complete This section is incomplete

Applicant Information

Name*
For E-Bill Notifications*
1. E-Bill Only
1. E-Bill and Printed Bill
Email Address*
Mailing Address*
City*
State*
Zip Code*
Phone Number*
Cell Phone Number*
Emergency Number*
Employer*
Work Number
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Co-Applicant Information

The Co-Applicant information will not be listed on the account but will be listed in the notes as the 2nd name on the property.
Name
Contact Number
Work Number
Email Address
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Service Address

Service Address*
City*
State*
Zip Code*
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Special Notes & Acknowledgments

For Property Management
Please note: Inspections are for 5 Business Days only for $15. If the service needs to be on longer than the three days, a full deposit will be required. The deposit is based on the services that are available to the property. A termination of service form must be signed by the applicant if the service is no longer needed.
For New Construction
Please Note: In order for the meter to be installed, the permit board must be visible for our field technicians; if it is not then the meter will not be installed.
Special Note: I understand that if the above service address is a construction site, that the City of Titusville will not be responsible for any damage, loss or theft of any portion of the water service including the water meter.
All repairs and/or replacements are the responsibility of the applicant and must be completed prior to the certificate of occupancy.
Acknowledgment
I, the undersigned, understand that I am responsible for all charges for above services requested, and will continue to be responsible for same until such time as I request written termination of service. I understand that non-payment will result in termination of utility services. I understand that when transferring my service to another location in the city limits, I must pay all outstanding charges and a new deposit if applicable.
I understand that new owners are held responsible for all previous owner debt (including liens) and must be paid when establishing a new account. If not paid, the balance will be transferred to the new owners account within 20 days or a pay arrangement must be established. I also understand that any deposit paid will be applied to the account on the final bill and any resulting credit will be refunded in 4 to 6 weeks from the date of termination.
I am also responsible for making sure that all faucets are turned off before the service can be established. The city is not liable for damages caused by water faucets or outlets turned on. I also understand that if I do not plan to be present at the time that the water service is connected and a tag is hung that I will need to make arrangements to be present when a field technician schedules a service visit. If a third trip is made, then a $15 service charge will be applied to the account.
You are signing below that you have received a copy of the City of Titusville Utility Ordinance and you have also read and understood the information provided.*
1. Check to Agree
Name of Responsible Party*
Date & Time*
Date & Time
Date & Time
To Complete your Form:
Click submit, and please email a copy of your driver's license and a signed lease agreement or signed warranty deed to CustomerService@Titusville.com.

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1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Co-Applicant Information

Service Address

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Special Notes & Acknowledgments

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