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2. Utility Account Number:*
3. Service Address:*
7. Owner Information Section:
9. Owner's First Name:*
10. Owner's Last Name:*
12. Owner's Mailing Address:*
13. Owner's Phone Number:
15. City:
16. State:
17. Zip Code:
21. Tenant Information Section:
23. Tenant's First Name:
24. Tenant's Last Name:
25. Tenant's Phone Number:
27. Tenant's Mailing Address:
    *Please provide, if mail is not being sent to the service location*
28. City:
30. State:
31. Zip Code:
32. Email Address
34. Date Tenant Is Moving In
    Date Tenant Is Moving In
38. Property Manager Information Section:
40. Property Manager's Name:
41. Property Manager's Phone Number:
43. Property Manager's Address:
44. City:
46. State:
47. Zip Code:
48. Date Manager is to Be Put On The Bill:
    Date Manager is to Be Put On The Bill:
52. Agreement and Signature
    By submitting this application, I (property owner) hereby authorize and request that the City of Anacortes send the utility bill to the above named tenant/property manager. I understand that I will remain liable for all charges for utility service at the above address, that such unpaid amounts for utility service constitute a lien on the above address being served, and that the City of Anacortes can discontinue service until all billings are brought current. Charges will continue to accrue. The tenant/property manager will have the right to change the level of refuse service and add additional garbage charges to the account. The City of Anacortes has no obligation to notify me when a billing becomes delinquent and any such failure to notify me shall not relieve me of my obligation to pay such billings. A new form must be completed for each new tenant and that no closing bills will be prepared at any time. It is my sole responsibility to keep current my contact information as well as any other information concerning this account, including any changes in tenant/property manager.
54. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
56. Electronic Signature*
57. Date signed:*
Leave This Blank:


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

    This field is not part of the form submission.

61. Submit

* indicates a required field