Account Request Form
01 N 3rd St. 254-298-5616
Temple, TX 76501 email@example.com
Service Start Date - (Weekdays Only)
Preferred Service Connection Time:
Service Street Address
Is Billing Address the same?
Billing Address (If different than Svc Address)
Billing Zip Code
Alt Phone Number
Business Tax ID #
Name of Person requesting service:
Would you like to recieve an e-bill?
Please select Yes or No
Yes, I would like to receive an E-bill
No, I do not want to receive an E-bill
Please Select One
E-mail and Paper Statement
By entering my full name and clicking ‘Submit’ below, I am providing my electronic
signature and verifying that the information I have provided on this form is true
and correct, and I am authorized to initiate new water service for the address
listed on this application.
Disconnection of service for non-payment does not close a utility account. The account may continue to bill until the account holder contacts the Utility Business Office to terminate the account. Customers will be held responsible for charges to the utility account as long as it is active in the customer’s name. Please contact the Utility Business Office to close your account when service is no longer needed.