Form Center

2. 

5. APPLICATION FOR RESIDENTIAL UTILITY SERVICES

7. Name
8. Date of Application
10. Service Address
11. Date to Start Services
13. Type of Service Address

    1. Primary Residence (Own)

    1. Landlord of Residence

    1. Renting as Tenant
15. Billing Address (if different than above)
16. Telephone
18. Employer
19. Work Phone
21. Spouse or Roommate's Name
22. Phone
24. Landlord Name (if Renting)
25. Landlord Phone
27. Landlord Address
29. Emergency Contact Info:

    Please designate a contact person not living in the same location to be notified in case of emergency or disconnection of service. It will be necessary for you to inform this person that they are your emergency contact person. 

31. Emergency Contact Name
32. Phone
34. Emergency Contact Address:

36. As the applicant for service, I request the City of Fairbury to furnish the following services as set forth in the City Ordinances and the service policies and conditions of the City of Fairbury.

38. Services

    1. Electric

    1. Water

    1. Sewer

    1. Garbage

40. I request the City of Fairbury to send my utility billing via:     

42. Billing Notices

    1. Mail

    1. Email

    1. Both Mail & Email
44. Email Address

46. For receipt of such services, I agree to pay to the Fairbury Light & Water Department all charges as determined by the rates approved by the Fairbury City Council. If selected, I authorize the City of Fairbury to enroll me in paperless billing and to send me only an electronic copy of my bill. I, the customer, agree to notify the Fairbury Light & Water Department when the services are no longer desired.

48. Applicant Signature
49. Date
51. Co-Applicant Signature
52. Date

54. Application must be signed in Office (612 D Street). Also, a deposit of $150.00 will be required.

Leave This Blank:


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

    This field is not part of the form submission.

58. Submit

* indicates a required field