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
Mailing Address City, ST ZIP
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
Co-Occupant Information Co-Occupant Name S.S.N. D.L.
Primary Phone (10 Digits Only) Secondary Phone (10 Digits Only) D.O.B.
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.