2. I (We) the undersigned, hereby make an application to the City of Edwardsville ''City'' for water service, sewer service, and trash removal services to be supplied to premises located at:
   Below please fill in the location of where the service will be.
4. Service Address*
6. City*
7. State*
8. Zip Code*
10. Location Type:*

    1. Residetial
    2. Commercial
11. For the service, I (We) agree to pay the City at the rates as prescribed in the effective schedule or schedules in the ordinances of the City as they exist from time to time and as amended, and to comply with the City's Rules and Regulations for such services. I We also agree to be responsible for all services used on said premises until forty-eight (48) hours after notice has been given at the Office of the City Clerk to discontinue the services. I (We) also agree to be responsible for all costs of collection incurred by the City, including collectior agencies, court costs, and attorneys' fees, to collect my account should it become delinquent. *

    1. I Agree

    Please select Agree to continue
13. First Name
14. Last Name
16. Business Name:
20. Account #
21. E-Billing

    1. Yes
    2. No
22. Phone Number
24. Email Address*
Leave This Blank:


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

    This field is not part of the form submission.

28. Submit

* indicates a required field