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 New Service * Name(s) on Account * New Address Street Address * Apt. City * State * Zip * Primary Phone * Secondary Phone Email Rent or Own * Rent Own New Landlord Name New Landlord Phone Number Have you had your utility service disconnected for non-payment within the past 12 months? * Yes No Driver's License Number * Previous Address Street Address * Apt. City * State * Zip * Primary Phone * Secondary Phone Rent or Own * Rent Own Previous Landlord Name Previous Landlord Phone Number Employer Employer Name Employer Phone Number Spouse or Roommate Information Name * Employer Name Employer Phone Number 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 20th 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. * Any Other Specific Instructions Leave this field blank
