Form Center

3. Today's Date*
   Today's Date
4. Date Service to Begin*
   Date Service to Begin
6. Applicant Name*
7. Additional Name
9. Service Address*
11. City
12. State
13. Zip Code
15. Mailing Address
    If different than service address
17. City
18. State
19. Zip Code
21. Phone*
22. Alternate Phone
23. Email
25. Applicant Status

    1. Property Owner
    2. Tenant
26. Property Use

    1. Residential
    2. Commercial
28. Have you had prior utility service with the Town of Prescott Valley?*

    1. Yes
    2. No
30. If yes, what was the service address?
32. City
33. State
34. Zip
36. Property owners can email a letter of credit from another utility company to ca@prescottvalley-az.gov
38. If transferring service, would you like to schedule a turn-off date?

    1. Yes
    2. No
39. Turn-off date
    Turn-off date
41. The undersigned referred to as Applicant, at the above service address, hereby agrees to pay all costs and fees due under this agreement including, but not limited to, attorney’s fees and court costs. The Applicant further agrees to be governed by the Ordinances/Regulations pertaining to water and/or sewer services as amended from time to time by Town Council. The Applicant also agrees as follows:

    1. A non-refundable service fee of $25 for technical and administrative services in providing the initial service to the customer.
    2. Utility charges will be billed on a monthly basis in accordance with authorized rate/fee schedules.
    3. Same day Turn On service is offered for completed applications received prior to 12:00 pm. For Termination of Service, a minimum of one business day notice is required.
    4. Town staff and contracted service technicians shall have access at all reasonable hours to the premises for the purpose of reading or testing meters. It is the applicant's responsibility to keep the meter unobstructed and accessible at all times.
    5. Payments may be made by cash, personal check, cashier’s check, money order or debit/credit card. Any bank returned item or dishonored check is subject to a $25 per check charge and delinquent account enforcement processes.
    6. Accounts are due and payable 20 days after the billing date. A delinquent processing fee of $5 per service (water and/or sewer) will be assessed on the 27th day after the billing date. A delinquent notice will be mailed on the 28th day after the billing date. Unpaid delinquent accounts are subject to disconnection after the 40th day after the billing date.
    7. Deposits are tendered herewith or exempted. Deposits shall either be applied to an applicant's utility account or refunded after 12 months consecutive, on-time payments. *Commercial and multi-family account deposits may vary.

43. Applicant E-Signature*
44. Date*
    Date
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field