2. Instructions
   Complete and submit the form below to start your City of Coralville utility service. We request five working days notice to start service. Start service date must fall on Monday through Friday, excluding holidays. For more information, contact Utility Billing at 319.248.1715.
6. Deposit
   A deposit is required for all residential rental and business accounts, and must be received in our office prior to the start service date.
8. Residential rental account deposit: $80 per unit.
10. Commercial account deposit: varies according to usage. Contact Utility Billing at 319.248.1715 for the deposit amount.
12. The deposit will stay on the account until the account is terminated. Deposits are applied to the final bill and any remainder will be refunded to the account holder. Deposits are non-transferable.
16. Customer Information
18. Full Name or Business Name*
20. Date of Birth*

    (must be 18 or older)

21. Account Type*

    1. Owner
    2. Renter
23. Service Address*
24. Mailing Address (if different from service address)
    
    After the account start date
26. Daytime Phone Number*
27. Email Address*
29. Start Service Date*
    Start Service Date
    If you are a renter, the start service date is typically the lease start date. If you are an owner, the start service date is typically your closing date. Starting service after the lease start date or closing date may result in an incorrect billing period.
31. I would like to receive my bill by:*

    1. ebill notification
    2. paper

    (ebill notification will be sent to the email provided above; paper copy will be sent to the mailing address provided above.)
35. Landlord Information
37. Landlord's Name
    Complete if you are a renter
38. Landlord's Phone Number
    Complete if you are a renter
42. Account Agreement*

    By submitting this form, I agree to pay for all utility bills for services provided by the City of Coralville. The account will remain in my name as listed above until the City of Coralville receives a Stop Service Request. I understand that all accounts are subjected to a non-refundable and non-transferable $30 activation fee which will be reflected on my first utility bill.

    1. Yes, I agree to the above
44. Additional comments
46. If you select "Receive email copy," please add noreply@civicplus.com to your email address book or safe sender list.
48. Today's date
    Today's date

    Today's date
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field