Your name*

Your Email*

Service Address*

Services Requested*
ElectricWaterSewerSolid Waste
Service Date*

Occupant Information
Is your Mailing Address the same as the Service Address?
YesNo

[group address-group]
Mailing Address

City, ST ZIP
[/group]

Primary Phone* (10 Digits Only)

Secondary Phone (10 Digits Only)

Employer*

Employer Phone* (10 Digits Only)

D.L.*

S.S.N.*

D.O.B*

Would you like to add a Co-Occupant?

NoYes

[group second-occupant]
Co-Occupant Information
Co-Occupant Name

S.S.N.

D.L.

Primary Phone (10 Digits Only)

Secondary Phone (10 Digits Only)

D.O.B.
[/group]

E-Billing Information
I hereby authorize the City of Goodland to E-Mail my utility bill for the above listed address to my personal E-Mail address as listed above.
With signing this agreement I understand that I will no longer receive a utility bill in the mail from the City of Goodland.
No, Send me a paper billYes, E-bill me

By checking this box, you accept that the utility services will not be started until submitting a photo id and deposits/connection fees to City Hall at 204 W. 11th St. Goodland, KS.