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2. BURLINGTON MUNICIPAL WATERWORKS
   500 N 3RD ST BURLINGTON, IA 52601 (319)754-6501

   500 N 3RD ST BURLINGTON, IA 52601 (319)754-6501

4. Service Address*

6. Mailing Address

8. Applicant Last Name*

9. Applicant First Name*

10. Middle Initial*

11. Suffix

13. If Business, Name of Business and Contact Name

15. NAME & PHONE # of Other Individual with Permission to Access this Account

17. Applicant Phone#*

18. Social Security# *

19. Driver's License / Photo ID (must upload)*

21. Email Address*

23. Service Start Date*

25. Agreement
    I agree to comply with the rules and regulations of the Burlington Municipal Waterworks and to pay charges due for water, sewer, storm water, trash, and miscellaneous charges at the above premises.

    I agree to comply with the rules and regulations of the Burlington Municipal Waterworks and to pay charges due for water, sewer, storm water, trash, and miscellaneous charges at the above premises.

27. Please Initial and Date*

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field