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2. I (We) the undersigned, hereby make an application to the City of Edwardsville ("City") for water service, sewer service and trash removal services for the following premises:
4. Address*
6. City*
7. State*
8. Zip Code*
10. Location Type:*

    1. Residential
    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 collector 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. User ID
18. Business Name:
22. Application Fee of:
23. Application Fee Taken By:
27. Prior Resident:

    1. Prior Resident
    2. Not Prior Resident
28. E-Billing

    1. Yes
    2. No
30. Phone Number*
31. Email Address*
33. Type of Residency

    1. Owner
    2. Tenant
34. Landlord's Name:
36. Residence

    1. Primary
    2. Rental
37. Driver's License Number*
38. State That Issued Driver's License*
40. On what date should services begin?
    On what date should services begin?
Leave This Blank:


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

    This field is not part of the form submission.

44. Submit

* indicates a required field