City of Hood River Utility Service Form Please Note: There is a $10 processing fee is applied to new and terminating accounts (applied to first & last bill)Effective Date* MM slash DD slash YYYY Move In or Move Out* Move In Move Out Own or Rent* Owner Renter Underground Irrigation System?* Yes No Occupant NamesOccupant Name #1* Occupant Name #2 AddressService Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone Number* Owner Information If you are the renter you must submit the Owner(s) information below. Owner(s) signature is REQUIRED for service to be set up.Owners NameName 1 First Last Name 2 First Last Name 3 First Last Owner PhoneOwner Email Owner(s) AddressOwners Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code I UNDERSTAND THAT IF I DO NOT PAY MY UTILITY BILL IN A TIMELY MANNER, THE OWNER OF THE PROPERTY WILL BE NOTIFIED. I ALSO UNDERSTAND THAT SERVICES MAY BE TERMINATED UNTIL PAYMENT IS RECEIVED. AS CONSIDERATION FOR UTILITY SERVICES PROVIDED BY THE CITY OF HOOD RIVER, I AGREE TO COMPLY WITH ALL APPLICABLE ORDINANCES, RESOLUTIONS, AND POLICIES OF THE CITY OF HOOD RIVER Please type your name in below for your signature: I have agreed to submit this form by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. Occupant Signature* First Last Occupant Acknowledgement* By checking this box and typing my name above it, I am electronically signing this document. Owners Signature* First Last Owner Acknowledgement* By checking this box and typing my name above it, I am electronically signing this document. CAPTCHANameThis field is for validation purposes and should be left unchanged.
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