Please complete this form to establish a new Village of Northfield water and/or sewer service account. Knowingly providing incorrect or false information invalidates this form and may constitute fraud.

Date to Establish Service*

Service Address*

Resident Name*

Billing Address (if different than service address)

Billing City, State, Zip (if different than service address)

Phone Number*

E-Mail Address*

If this is a rental property, provide the name and address of the property owner or management company

Upload a legible copy of your current driver's license or alternate government-issued photo ID*

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By electronically signing and submitting this form, I recognize that I am assuming the payment responsibility for this utility account from the date provided forward.

Signature of New Responsible Party*