Request Information

Reason for Request*field type radio button
Reason for RequestNewTransferOther
Property Address*field type single line
This is the address where you are requesting utility service be connected.
Input blocked. Maximum character limit of 4000 characters reached.
Do you own or lease the property?*field type radio button
Do you own or lease the property?OwnLease
Please upload Proof of Ownership.field type file upload
Please upload a copy of your Lease.field type file upload
Desired Connection Date*field type date
Desired Services*field type checkbox
Contingent upon Dothan Utilities being the service provider for each service type.
Desired ServicesElectricSewerWaterIrrigationVapor LightsOther

Business Information

Type of Business*field type radio button
Type of BusinessSole Proprietor/PartnershipLLC/LLPCorporationOther
Social Security Number (SSN) or Federal Identification Number (FEIN)*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Legal Business Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
D/B/A Namefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Business Address*field type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Is the mailing address the same as the business address? This will be the address all billing and utility correspondence is sent to.*field type radio button
Is the mailing address the same as the business address? This will be the address all billing and utility correspondence is sent to.YesNo
Mailing Addressfield type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country

Please note that a written letter of authorization will be required for anyone other than the applicant to conduct business, make inquiries, transfer services, or terminate the account.
Applicant Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Applicant Phone Number*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Applicant Email Address*field type email
Please upload a copy of your state-issued identification (Driver's License, Military ID, Passport, etc).*field type file upload

Applicant's Association to the Business*field type radio button
Applicant's Association to the BusinessOwnerPartnerBoard MemberManagerEmployeeOther
Authorization Letterfield type file upload
I, as the applicant, agree to provide the City of Dothan construction and maintenance easement, including ingress and egress, over, under, across, and upon the property for the purpose of providing electrical and/or water service to the property address.
I understand that installation fees, connection fees, and/or required deposits must be paid before these services will be connected. Upon connection, I will be responsible for these services until I request the service be terminated, or the service is transferred to another name.
I understand that if suit is brought to collect a delinquent bill, the customer is responsible for a reasonable attorney's fee and court costs.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) the document will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
*field type checkbox
I agree.
Signature*field type signature
Date*field type date
DateTime captured on form submission