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2. Submission Instructions

   All Real Estate Agents requesting utility services must have this contract completed, signed by the broker of the company, and on file with the City of Modesto to activate service. Please provide the following items:

4. Required Items*

   1. Completed City of Modesto Real Estate Agent Contract signed by the agent;
   2. Copy of your business license with the City of Modesto;
   3. Copy of Agent's California Driver's License

6. In addition, a security deposit may be required in accordance with MMC 11-6.02.  All requests will be processed within 48 hours from time of receipt. Please fax completed form to the City of Modesto at (209) 491-5920. 

   *WHEN SERVICE IS NO LONGER NEEDED, WRITTEN REQUEST TO TERMINATE SERVICE IS REQUIRED. *

10. Name of Real Estate Agent*
11. Property Owner *
    Name of Property Owner for the property which the Real Estate Agent is managing and requesting services.
13. Agent's Tax ID Number*
14. Agent's Driver's License Number*
16. Billing Address*
17. Service Address*
19. Phone Number*
20. Fax Number
22. Does the owner need to receive a copy of the bill?

    1. Yes
    2. No
24. Street Address*
26. City*
27. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
28. Zip Code*
30. I, the above listed agent, do hereby agree that in signing this document I am requesting the City of Modesto to place the utility services in my name (water, sewer, storm drain and garbage) until I request in writing that services be terminated. I understand I am responsible for payment of the services each month. If the final bill is left unpaid, it is understood I will not be allowed to have any new accounts set up until all past due balances are paid in full.
32. Responsible Party Signature
33. Date
34. Account Number
36. Property Vacancy

    Does the property have garbage cans? (We do not bill for garbage for multi-family properties.)

    1. Black
    2. Green
    3. Blue
    4. No Can
    5. Not Sure
38. Please select from the following:*

    1. Start Service
    2. Stop Service
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