Form Center

2. APPLICATION FOR UTILITY SERVICE

   AFTER SUBMITTING COMPLETED APPLICATION PLEASE CALL 540-372-1182.  BE PREPARED TO PROVIDE DRIVER’S LICENSE NUMBER AND SOCIAL SECURITY NUMBER FOR INDIVIDUAL APPLICANT OR FEDERAL ID FOR BUSINESS APPLICANT.

   EFFECTIVE 7/1/2021 THE CITY OF FREDERICKSBURG HAS ADOPTED A $3 PER BILLING CYCLE RECYCLING FEE FOR CITY UTILITY CUSTOMERS.

4. First Name*
5. Last Name*
6. Middle Initial
8. If business, name as it should appear on the bill:
10. Service Address:*
12. Mailing Address:*
14. Phone:*
15. Alt Phone:
17. Email:*
21. Water:
23. Begin Date:
    Begin Date:
27. Trash:

    (Additional charge)

29. Begin Date:
    Begin Date:
33. Recycling:
35. Begin Date:
    Begin Date:
39. Print Name:
41. Signature:*

    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.

    Please Verify that all fields are correct before Submitting.

    1. I Agree
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field