Welcome to Cuba City! We're happy to be your new utility provider. Please submit the form below to establish service at your new residence. We are available for connects and disconnects Monday through Friday. We do require at least a 24-hour notice. Customer Information Date of Application * Requested Date to Begin Service * Requested Name(s) on Utility Bill * Additional Adult Occupants New Service Address Street Address * Apt. City * State * Zip * Primary Phone * Secondary Phone Email Ownership Status * Rent Own select one New Landlord Name (if renting) New Landlord Phone Number (if renting) Applicant's Driver's License Number * Applicant's Date of Birth * Have you been billed by Cuba City Light & Water in the past? * yes no Previous Address Previous Street Address * Apt. City * State * Zip * Have you had your utility service disconnected for non-payment within the past 12 months? * Yes No Mailing Address (if different from your new service address) Mailing Street Address City State Zip You agree to the following (please initial): I agree to give access to my meter(s) at all times. * I agree to be responsible for all amounts due while service is in my name. * I understand that bills are due by the 5th of the month. Bills not paid by the due date will be sent a disconnection notice and will be subject to termination of service(s). * I understand that it shall be my responsibility to notify the utility office when service is to be terminated or changed from my name. * Applicant's Signature * Type in your full name in lieu of electronic signature. Leave this field blank