Application for Utility Services

2. Date of Service*
   Date of Service
3. Purchased or Renting*
   -- Select One --PurchasedRenting
4. Please Note:
   If you are renting property, a Tenant Deposit in the amount of $150 is due to the City of Dyersville prior to service connection. Please contact city hall to make payment.
6. Name(s) As To Appear on Account*
7. Spouse/Fiance/Signifcant Other Not Listed on the Account
9. Address Moving Into*
11. Mailing Address if Different from Service Address
13. Address2
15. City
16. State
17. Zip
19. Phone/Cell No.*
20. Additional Phone No.
21. Email Address*
23. Social Security No.
24. Date of Birth*
    Date of Birth
25. Spouse Soc. Security No.
26. Spouse Date of Birth
    Spouse Date of Birth
28. Business Fed. ID No.
29. Previous Address
    If you need service disconnected at another address, please provide address and date of disconnection.
31. Automatic Bank Withdrawl Form
    Authorization for Automatic Bank Withdrawl

    If you are interested in having your bill automatically deducted from your checking or savings account, please click the link above.
33. Code Red Notification
    Emergency Notification System| Community Notification

    If you want to be added to the Dyersville CodeRED emergency notification list, please click the link above.
35. Proof of identification
    Please upload a copy of a government issued photo I.D. If a government photo I.D. is not available, please upload another type of photo identification.
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field