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2. Print off a blank Application for Disconnection of Utilities Form if you do not wish to submit your form electronically:
   Application for Disconnection of Utilities
4. Effective Date of Disconnection:*
   Effective Date of Disconnection:
5. Utility Account Number:*
7. Account Type:*

   1. Residential
   2. Commercial
8. Discontinue Services For:*

   1. Water
   2. Sewer
   3. Garbage
10. Applicant Name:*
12. Service Address:*
14. Forwarding Address for Final Bill:*
16. Primary Phone Number:
17. Secondary Phone Number:
19. 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.
    3) You may still be required to provide a traditional signature at a later date.*

    1. I agree
21. Electronic Signature:*
23. The personal information on this form is collected under the authority of the Municipal Government Act and is protected under the provisions of the Freedom of Information and Protection of Privacy (FOIP) Act. If you have any questions about the collection, use and protection of this information, please contact Red Deer County at 403.350.2150.
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field