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2. PLEASE CHECK IF APPLICABLE:

   1. Send duplicate bill to tenant
   2. Police or Fire Alarm System
4. All home and business owners must apply for and receive an alarm system permit before use or possession. There is a one-time fee of $50.00 for the alarm permit. Click the link below to fill out the online application.
   Alarm Permit Application
6. UPLOAD STATE OR GOVERNMENT ISSUED PHOTO ID:*
8. DATE OF APPLICATION*
   DATE OF APPLICATION
9. SERVICE START DATE*
   SERVICE START DATE
11. SERVICE ADDRESS*
12. MAILING ADDRESS (if different from service address)
14. NAME OF BUSINESS*
15. PHONE NUMBER*
17. OWNER'S NAME*
18. PHONE NUMBER*
20. E-MAIL*
22. LOCAL CONTACT/MANAGER*
23. PHONE NUMBER*
25. LOCAL CONTACT/MANAGER ADDRESS*
27. TYPE OF BUSINESS*
29. I, the undersigned, do hereby represent that I am the OWNER of the legal or equitable title to the premises stated above; in the City of Moline, Illinois or that I hold such legal or equitable title in conjunction with my co-owner.
31. The undersigned OWNER does hereby GUARANTEE PROMPT PAYMENT when due of all bills for water and/or sewer furnished at the said premises even though not occupied by the said OWNER until said OWNER shall notify the Water Department to terminate such services. This application and acceptance thereof by the City shall constitute a contract between the City; and the undersigned parties, and such contract, shall be subject to all applicable City Ordinances, Rules and Regulations, now in force, or hereafter adopted by the said City or by the Water Department.
33. 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.
35. Electronic Signature*
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field