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2. City of Pilot Point Residential Application for Utility Services

   Please complete the following application to have services connected or transferred.

4. Photo ID Required to Complete Application Process*

   A photo identification is required for an application to be considered complete. You MUST submit a copy of your photo identification.

    Fax: 940-686-4338 Attn: Utility Billing

   Drop Off: City Hall 102 E Main St. Pilot Point TX 76258

   Email: [email protected]

   Incomplete applications will NOT be processed.

   1. I agree to submit a photo identification to complete my application.
6. Today's Date*
   Today's Date
7. Service Start Date*
   Service Start Date
   Service calls are made between 3:00PM-5:00PM on the requested start date. It is REQUIRED that someone be at the residence at the time of connection due to the possibility of an outlet being open. An open outlet can cause flooding of the premises.
9. Service Address*
10. Service Type*

    1. NEW – New Resident
    2. TRANSFER – Current Resident
    3. LANDLORD-14 Day Connection
    4. CONSTRUCTION-Builder

    Please choose which type of account you will be opening.
12. Primary Contact
14. First Name*
15. Last Name*
17. Phone Number*
18. Work Number
20. Email Address
21. Mailing Address

    1. Yes
    2. No

    Is your mailing address the same as your service address?
23. Mailing Address
25. Bill Delivery*

    1. Mail Only
    2. Email Only
    3. Both Mail and Email

    How would you like to receive your monthly utility bill?

27. Transfer

    1. Yes
    2. No

    Would you like to transfer service from another location in Pilot Point?
28. Transfer of Service Address
    Please provide the service address for the account you would like to transfer from.
29. Date for Transfer
    Please provide the date that you would like services disconnected at the address you are moving from.
31. Service History *

    1. Yes
    2. No

    Have you previously had service in the City of Pilot Point?
32. Previous Service Address
    Please provide the service address for any account you have had with the City of Pilot Point.
34. Secondary Contact
36. First Name
37. Last Name
39. Phone Number
40. Work Number
42. Email Address
44. Emergency Contact
46. First Name*
47. Last Name*
49. Phone Number*
50. Work Number
52. Email Address
54. Would you like to set up Auto Payment?*

    1. Yes, I would like to set up Auto Payment
    2. No
56. Automatic Draft Form
    Please Click Here to complete the Auto Payment Form
58. Confidential Request

    1. I hereby request confidentiality of my personal information by the City of Pilot Point's Utility Billing Division
    2. I hereby withdraw my request for confidentiality
60. Customer Signature*
    By signing above, I agree to applicable service connect fees and understand my monthly bill is due on or before 5:00 PM on the 5th of every month. Payments received after 5:00 PM on the 5th will incur a 10% late charge fee. Payments received after the 15th of the month are subject to disconnection and applicable fees. See service agreement for service fee amounts and additional charges and fees for service.
61. Applicant Type*
    -- Select One --OwnerRenterLandlord
63. City of Pilot Point Service Agreement and Terms of Service Agreement
    Please Click Here to read Service Agreement
65. Customer Signature*
    I have read and understand the City of Pilot Point Service Agreement and the Terms of Service Agreement.
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field