Required fields are marked with asterisks (*)

Commercial Service Contract - Owner

The information collected on this form will be used by the City of Belleville to establish and maintain a service connection and for billing and collection purposes.

Service Address

Street Number and Name:

Unit Number (if applicable):

Account Number:

Client Code:

Effective Date:

Customer Information

Business Name:

Common Name:

Mailing Address

Street Number and Name:

Unit number (if applicable):

City:

Province:

Postal Code:

Email Address:

Telephone:

Fax Number:

Would you like E-billing? (select one)

Yes

Signator

We require and will verify identification

First and Last Name:

Position: