City of Zephyrhills Utility Account Application/Change Form The under signed, as owner, agent, resident, or occupant of hereby applies for water, sanitary sewer, and/or solid waste services to said premises and agrees to pay for said services at the rates specified by the City of Zephyrhills Code of Ordinances, The undersigned further agrees to comply with and be bound by all rules, regulations, and ordinances of the City of Zephyrhills pertaining to water, sewer, and/or solid waste services and specifically agrees to pay all applicable charges. New Account: _____ RESIDENTIAL _____ COMMERCIAL Name _____________________________________________________________________________________ Doing Business As _____________________________________________________________________________________ Service Address _______________________________________________________________________________________ Mailing Address (if different) ____________________________________________________________________________ Phone Number ______________________________ E Mail Address (optional) ____________________________________________________ For E-Bills Date to Connect Service ___________________________ Dumpster ________________________________________________________________ Note: Copy of rental agreement or lease must be shown if applicant does not own the property, The City of Zephyrhills recognizes that an individual's driver's license number is a unique form of identification that can be utilized to obtain sensitive information regarding that particular individual. However, the City of Zephyrhills must collect Drivers License numbers under certain circumstances in order for the City to be able to properly perform its duties and functions as a municipal corporation and in order to ensure that such duties and functions are performed accurately and efficiently. THE CITY OF ZEPHYRHILLS COLLECTS YOUR DRIVERS LICENSE NUMBER ONLY FOR THE FOLLOWING PURPOSES: CLASSIFICATION OF ACCOUNTS IDENTIFICATION CREDIT WORTHINESS OR COLLECTIONS BILLING AND PAYMENTS DATA COLLECTION, RECONCILIATION AND TRACKING NEW UTILITY ACCOUNT APPLICATION POLICE STATEMENTS AND ARRESTS FOR THE VERIFICATION OF IDENTITY Each individual who provides a Drivers License number to the City of Zephyrhills shall be provided with a copy of this notice. _________________________________________________ _______________________ Signature Date