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2. Current or Previous Customer? Please provide your most recent service location address
4. Requested Date to Connect Service (Monday through Friday only, excluding holidays)*
   Requested Date to Connect Service (Monday through Friday only, excluding holidays)
5. Account holder FULL NAME or FIRST and LAST NAME*

   Can ONLY be one individual

7. Address to Connect Utilities*
9. Mailing Address for Utility Account if Different than Service Address
11. Contact Phone Number*
12. Email Address*
14. Drivers License/ID Number*

    Entities/Businesses please enter EIN here

15. Drivers License/ID State of Issuance*
17. Date of Birth*

    Entities/Businesses please enter 00-00-0000

19. I authorize the City of Ashland to enroll me in paperless billing.

    1. Please use the email address I have provided.
21. Letter of Credit Coming From
22. I don't have a Letter of Credit and understand that I will be billed the deposit. If I do not pay the deposit by the due date of my first bill, I understand that my services will be subject to disconnect per AMC 14.02.020.

    1. I agree to the above statement

    Ashland Municipal Code 14.02

24. Additional Contact Person authorized to receive information on the utility account
26. Ashland Fiber Network (AFN)

    Sign up for AFN internet service and find out about bundled services offered by AFN’s retail partners. 

28. By submitting this form, I authorize the City to activate my utility account and agree to abide by the rates, rules and regulations of the City.

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field