***Please note, all fields must be filled out. If not applicable please enter NA. Thank you.
Name: Address:
City: State: Zip:
Mailling Address if Different:
Driver's License or Social Security Number: Date of Birth:
Home Phone: Cell Phone:
Email Address:
Name of Employer: Number of Occupants:
Owner or Renter: OwnerRenterSelect One
Enroll in Paperless Billing via Email: YesNoSelect One
Receive Utility Notifications: YesNoSelect One
Date to Start Service:
***Please Note***
A deposit of $200 is required of all new Cotati residents in addition to a $35 non-refundable administrative services fee. This deposit and initial fee will be added to the first bill service.
Please initial for acknowledgement: