Form Center

2. 
4. SERVICE START DATE*
   SERVICE START DATE
5. OWNER OR TENANT*
   -- Select One --TENANTOWNER
6. LANDLORD NAME*
7. LANDLORD PHONE NUMBER*
9. PROPERTY TYPE*
   -- Select One --Residential Commercial
10. FIRST NAME*
11. LAST NAME*
12. PHONE NUMBER *
14. BUSINESS NAME
16. ADDITIONAL CONTACT NAME*
17. ADDITIONAL CONTACT PHONE NUMBER *
19. PROPERTY ADDRESS*
20. CITY, STATE AND ZIP CODE
    VERNAL, UTAH 84078
22. MAILING ADDRESS (if different from service address)
23. CITY, STATE AND ZIP CODE
25. Email Address*
27. EMPLOYMENT STATUS*

    1. EMPLOYED
    2. NOT EMPLOYED
    3. RETIRED
28. EMPLOYER'S NAME *
29. EMPLOYER'S PHONE NUMBER *
31. PROOF OF OWNERSHIP*
32. LEASE OR RENTAL AGREEMENT*
34. I UNDERSTAND THAT A DEPOSIT IN THE AMOUNT OF $150.00 IS REQUIRED.

    1. To pay, please contact Vernal City at 435-789-2255
36. UTILITY AGREEMENT*

    1. By checking this box, I am signifying that the name provided at the top of this page is my electronic signature and I have read and agree with the following disclaimer:

    I, the undersigned owner of the above property, understand that utility billings are due thirty (30) days after billing. Should I become delinquent in payment of any such billing, Vernal City shall have the right to demand payment of said billing in full, plus interest at 1.5% per month, which is 18% APR, or suspend my utility service, which would require a Forty Dollar ($40.00) reconnect fee for service to be reinstated. In the event that the utility billing account is turned over for collection I agree to pay all interest at 1.5% per month, which is 18% APR, plus all collections fees, court costs and attorney fees necessary for the collection of said delinquent account.

38. OWNER RENTAL OPTIONS*

    1. By checking this box, I am signifying that the name provided at the top of this page is my electronic signature and I have read and agree with the following disclaimer:

    OWNER RENTAL OPTIONS if the above property, owned by me, becomes a lease or rental property, I understand the following will apply: 1.) I will be responsible for utility service and request that all utility bills be sent to me. 2.) I will be responsible for utility service and request that all utility bills be sent to the tenant at the service address and understand a utility deposit in the amount of $150.00 will be paid by the tenant. I further understand and agree in the event an unpaid utility balance left owing by the tenant, I , as the property owner, will be responsible for said unpaid balance, plus interest at the rate of 1.5% per month, which is 18% APR, plus all collection fees, court costs and attorney fees necessary for the collections of said delinquent account.

40. UTILITY AGREEMENT *

    1. By checking this box, I am signifying that the name provided at the top of this page is my electronic signature and I have read and agree with the following disclaimer:

    I, the undersigned tenant of the above property, understand that utility billings are due thirty (30) days after billing. Should I become delinquent in payment of any such billing, Vernal City shall have the right to demand payment of said billing in full, plus interest at 1.5% per month, which is 18% APR, or suspend my utility service, which would require a Forty Dollar ($40.00) reconnect fee for service to be reinstated. In the event that the utility billing account is turned over for collection, all interest at 1.5% per month, which is 18% APR, plus all collections fees, court costs and attorney fees necessary for the collection of said delinquent account. Further release is hereby given to Vernal City to obtain any and all such information from employer or references as may be deemed necessary to process this application for service or effect collection of any unpaid balance due. I, the undersigned, hereby certify that the information given above is true and correct.

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 Submit and Print

* indicates a required field