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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. Billing Address:*
14. Phone:*
15. Alt Phone:
17. Email:*
21. Water:
23. Begin Date:
    Begin Date:
24. Terminate Date:
    Terminate Date:
28. Trash:

    (Additional charge)

30. Begin Date:
    Begin Date:
31. Terminate Date:
    Terminate Date:

33. Upon termination of trash service please place cans at the curb for pickup.

    Schedule changes for trash pickup due to weather/holidays are announced at www.fredericksburgva.gov.

    Sign up for trash alerts at www.fredericksburgalert.com.

37. Recycling:
39. Begin Date:
    Begin Date:
40. Terminate Date:
    Terminate Date:
44. Print Name:
46. 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.

    1. I Agree
50. No Deposit Requried:
51. Deposit Required:
52. Equifax Tracking:
54. CID:
55. Account:
56. Book:
58. Trash:
59. WO:
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field