Customer Information
Name(s) on Account:
Applicant Type:
Drivers License or Tax ID #:
Primary Phone #:
Email:
New Billing Address:
Required Documents
Drivers License or Tax ID#/EIN (Residential) or (Commerical)
Upload DL or Tax ID#/EIN
Lease/Proof of Ownership (New & Transfer Service Only)
Upload Lease/Proof of Ownership
TRANSFER SERVICE Shut Off Date:
v
Turn On Date:
v
Account #:
Address Transferring From:
Address Transferring To:
Reason:
ACTIVATE SERVICE Start Date:
v
Service Address:
CANCEL SERVICE Cancel Date:
v
Account #:
Service Address:
TEMPORARY SERVICE
(maximum of 2 weeks)
 Turn On Date:
v
Turn Off Date:
v
Account #:
Please read the disclosures below. Check next to each statement to indicate you have read and understand the information completely.
A Lien will be placed on the property if an account in the owner's name remains unpaid. Customers requesting that service be interrupted will pay the monthly base facility charge during the period of interruption. There is processing fee for paying with a debit/credit card/e-check, which will be paid directly to the City's payment vendor. Residential deposits shall be held in a non-interest bearing account. If a customer has a record of timely payment over a continuous 12-month period, then the City shall apply that deposit to the account. Otherwise, the deposit will be applied against the final bill and any credit remaining will be refunded. Deposits/bills paid via checks that are returned unpaid will result in immediate service interruption without further notice. The customer is responsible for access to the City meter. The customer will be responsible for the cost to repair or replace the meter if it is lost or damaged. (Code of Ordinances Sec 58-3).
Customer Signature (type name):
v
Date: Please be advised that all information provided on this application is considered Public Record, and the City of Melbourne is required to make the information available upon request, with the exception of information designated by law as "exempt" or "confidential".
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