Enrollment and Authorization

Enrollment and Authorization
Please check to confirm
Please select the one that applies
Account Number
Applicant's Information
Applicant Name

First NameLast Name
Daytime Phone Number
Add your best contact to reach you.Format: 000-000-0000.
E-mail Address
example@example.com
Is the service address the same as the billing address?
Service Address

Street Address

Street Address Line 2

CityState

Zip Code
Billing Address

Street Address

Street Address Line 2

CityState

Zip Code
Financial Information
Bank / Financial Institution
Is the account Checking or Savings?
Checking / Savings #
ABA/Routing #
Attach a copy of a voided check for the checking account or a deposit slip for savings account

Max file size: 25 MB, Accepted file types: .pdf, .jpg, .png
Cancelof
Applicant Agreement

Applicant must read and sign
By signing below, I. {applicantName}, hereby authorize the City of Coral Springs to initiate debits electronically, by paper means or by any other commercially accepted method, to my checking account, {checking70} . I authorize my financial institution, {bank}, to debit the same amount.

I also, by signing below, acknowledge that I am the person who has contracted with the city for water service at the location, {serviceAddress}.
By typing my name in the below space, I am electronically signing this form. My signing this electronic signature certifies the information to be true, accurate, and complete.

First NameLast Name
Date Submitted

MonthDayYear
Hour MinutesAM/PM Option
Should be Empty:

Enrollment and Authorization

Applicant's Information

Financial Information

Applicant Agreement