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2. Business Name*
3. Email Address
5. First Name*
6. Last Name*
8. Property Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number
15. Alt Phone Number
16. Possession Date*
    Possession Date
18. Billing Address (if different from property address)
20. City
21. State
22. Zip Code
24. Garbage Service Type*

    1. Curbside ($17.37/month)
    2. Garage/Back Door ($28.14/month; Not over 150' from Street)
    3. No Garbage Service
25. Date to Begin Garbage Service
    Date to Begin Garbage Service
26. Renter or Owner*

    1. Renter
    2. Owner
28. Additional Notes or Requests
30. 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. I/We hereby make application to the City of North Canton for utility service to said premises and hereby agree to pay all rentals and other charges for service at the due dates and to conform to all rules and regulations of the City of North Canton now or hereafter in force, pertaining to such utility service.

    1. I agree.
32. Electronic Signature
34. Date
    Date

    Date
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field