Leasing Agent Service Request : Daphne Utilities

Owner/Property Managers Name:*

Property Street Address:*

Street Address Address Line 2 City State ZIP Code

Date to Connect Services:*

Billing Address:*

Street Address Address Line 2 City State ZIP Code

Contact Phone Number:*

Email

By completing this form, I am officially requesting utility services to be transferred into my name at the above indicated property address. I understand that I am fully responsible for all charges that are billed to this account starting on the “date to connect services” listed on this form. Services will remain in my name until I contact Daphne Utilities to have them discontinued or until a new tenant assumes services in their name. I also understand that by submitting this form, that I will adhere to the terms and conditions that are stated in the signed Application for Utility Services form that is currently on file with Daphne Utilities.

Last 4 Digits of Social*

Verification

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For Information on Garbage Services, please visit the City of Daphne's website HERE.

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