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2. Application for Services with the City of Beach

4. Only available for people buying a property. Sorry renters, we do collect a $75 deposit so please stop in.

6. First Name*
7. Last Name*
8. Applicant's Phone #:*
   It will only be in our system, not in a database.
10. Applicant's Street Address*

    House number & street address of your new house

12. Own or Rent*
    -- Select One --OWNRENT
14. Applicant's Mailing Address*

    This is where the water bill will be mailed. If you happen to know the +4 of your zip code that would be very useful.

16. Applicant's E-mail Address:*
18. Emergency contact
    In the event of an emergency regarding water or sewer service at the above address we ask for an alternate contact name & phone #
19. Alternate Contact Info.
21. Contract

    I understand the City of Beach requires full payment of water, sewer and garbage by the 21st of each month. I understand that should my account become delinquent, the City of Beach has the authority to discontinue service to my residence. In the event you are a renter, the City of Beach will notify the owner when the account becomes delinquent. Payments received after the 21st of the month is subject to a $15 late fee (applied on next months' water bill). City of Beach Ordinance requires garbage to be bagged and placed in containers for collection. A $25.00 non-refundable fee will be charged to accounts needing water service reconnected. By providing an email address or a cell phone number above, you are agreeing to be sent reminders and disconnection  notices by those means only.

23. Notifications

    You can also get notifications from our website calendars.

24. Text or Email preference

    1. TEXT

    1. EMAIL
26. Authorization*

    By checking this box I agree to the terms of this contract.

    1. .
27. Comments:
29. INFORMATION FOR GOVERNMENT MONITORING PURPOSES

    This following information is requested by the Federal Government in order to monitor compliance with applicable Federal Civil Rights laws. You are not required to furnish this information, but are encoraged to do so. The law states that a provider of services may neither discriminate on the basis of this information, nor on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations the provider of services is required to note race, ethnicity and sex on the basis of visual observation or surname.

31. Sex
    -- Select One --FemaleMale

    Choose one based on who is signing this form

33. Ethnicity-optional
    -- Select One --Not Hispanic or LatinoHispanic or Latino

    Choose one

35. Race-optional

    Mark one or more

    1. White
    2. Black or African American
    3. American Indian/Alaskan Native
    4. Asian
    5. Native Hawaiian or Other Pacific Islander
39. New bill instructions
    Your new bill will start the business day immediately following when this is received. We bill for the previous month usage. Ex: you fill out this form on June 4th so your service will start on the 5th, then your first bill will be sent to you July 1st.
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field