Section 1 of 1 in this document

City of Panama City

Online Utilities Service Activations or Cancellations

Type of Service

Residential

Commercial

D/B/A

EIN

Service Options

New Service

Transfer Service

Cancel Service

Secondary Account

Name Change (please call for instructions)

Deactivation and Activaton Dates must be within 10 days of the other. Service at current address and new address may overlap if needed.

PERSON LIABLE FOR PAYMENT

Applicant First Name

Applicant Middle Name

Applicant Last Name

Account Number

Applicant Email

Applicant Phone Number

Applicant Last 4 of SSN

Employer

Name

Phone Number

Position Held

Business Phone Number

Relative Phone Number

Is There Other Person(s) That Can Act For You?

Yes

Authorized Person First Name

Authorized Person Last Name

Authorized Person Last 4 of SSN

Is there another person you would like to list?

Yes

2nd Authorized Person First Name

2nd Authorized Person Last Name

2nd Authorized Person Last 4 of SSN

Is there a Landlord?

Yes

Landlord First Name

Landlord Last Name

Related to Landlord?

Yes

How Related?

If you are completing this application from a smartphone or tablet, snap a picture of your Govt. issued picture I.D. along with the cover page of your lease and attach to the application in the fields below. Most all file formats are accepted (PDF, JPG, PNG TIFF etc).

Upload Copy of Photo ID

Click Here to Upload

Copy of Lease/Purchase Agreement OR Proof of Residency

Click Here to Upload

BY SIGNING BELOW YOU AGREE TO THE FOLLOWING

The undersigned applicant for residential water/sewer/garbage service states that the information provided in this application for city utilities is true and accurate to the best of applicant's knowledge. Applicant also understands that all charges are due as billed and accepts total responsibility for payment of all charges incurred for the services provided, including reasonable attorney's fees and costs incurred for collection of the unpaid balance.

Furthermore, the undersigned applicant consents that water services provided at the location listed may be turned on without applicant or applicant's representatives present. Applicant further agrees to hold the City of Panama City and its employees HARMLESS should the property, building(s) or premises incur damage as a result of water connection.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Receipt

You will be provided with a Receipt upon submission.

City of Panama City

Online Utilities Service Activations or Cancellations

Type of Service

Service Options

Service Address

Current Address

New Address

Deactivation Date for Current Address

Activation Date for New Address

Requested Activation or Deactivation Date

Applicant Date of Birth

Employer

Previous Business Account Address

Bill Delivery Address:

Forwarding Address

Nearest Relative Not Living With You

Relative Address

Is There Other Person(s) That Can Act For You?

Authorized Person Date of Birth