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Commercial Water/Sewer Application

  1. PLEASE CHECK IF APPLICABLE:

  2. *** GOVERNMENT ISSUED PHOTO ID REQUIRED

    Fax to: (309) 524-2074 Email to: kverbeke@moline.il.us

  3. 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.

  4. 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.

  5. 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.

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  7. This field is not part of the form submission.