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2. Application for Water Service

   This form is an application for new water service with the City of Jesup. Upon submitting this form, you must present the following: Drivers License or State issued ID, a copy of your rental agreement or closing papers, and a Deposit of $125 and $40 Connection Fee. Any outstanding bills due must also be paid in full prior to new service. Upon completion of this form you must call City Hall at (912) 427-1313 or visit us at 162 E. Cherry Street in Jesup to complete payment for your service request. Service will not be connected until payment has been received.

4. First Name*
5. Last Name*
7. Business Name
   FOR COMMERCIAL ACCOUNTS, please list the name of the business if you would like the account listed under your business.
9. Applicant Phone Number*
10. Alternate Phone Number
12. Service Address Street Number*
    Address of requested water service in Jesup
13. Service Address Street Name*
14. Apt #
16. ZIP*
17. Date of Service Connection*
    Date of Service Connection
    Please enter date you would like service to begin. ****Note service is only connected on Mondays, Wednesdays, and Fridays.
19. Billing Address Street Number*
    Address where bills should be mailed
20. Billing Address Street Name*
21. Apt #
23. City*
24. State*
25. ZIP*
27. Place of Employment*
28. Employment Phone Number
30. Spouse First Name
31. Spouse Last Name
33. Spouse Place of Employment
34. Spouse Employment Phone Number
36. Type of Service Requested*

    Please select one:

    1. Residential
    2. Commercial
38. Property Type*

    1. Own Home
    2. Rental
39. Landlord Name
41. Name of Closest Relative Not in Home*
42. Phone Number of Relative*
44. Address of Relative*
46. City*
47. State*
48. Zip*
50. Please upload a copy of rental agreement or closing papers
52. Electronic Signature*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application 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.

    1. I Agree
54. Signature*
    Please type your first name. middle initial, and last name.

56. A copy of your Drivers License or State issued ID, and a copy of your rental agreement or closing papers is required. Please mail to PO Box 427, Jesup, GA 31598, bring in person to City Hall (162 E. Cherry St. Jesup, GA 31546), or email the water department staff at btabb@jesupga.gov or rkinard@jesupga.gov

Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit Submit and Print

* indicates a required field