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2. In order to process your application, we ask you to provide the following information.

   If you would prefer to complete the application over the phone, contact Customer Service at (704) 455-5614 to enroll in auto draft.

4. First Name*
5. Last Name*
7. Phone*
9. Address*
11. City*
12. State*
13. Zip Code*
15. I Would like to Enroll in E-Billing*

    1. Yes

    1. No
16. Email Address
20. This authorization will remain in effect until I notify the Town of Harrisburg that I no longer desire this service, allowing reasonable time to act upon my notification. I have the right to stop payment of a debit entry by notifying my financial institution. This action must be taken, at least, 3 business days prior to the scheduled debit.
    
    I understand that if corrections of the debt amount are necessary, it may involve an adjustment (debit or credit) to my account. If an erroneous debit entry is charged to my account, I have the right to have the amount of the entry credited to my account by my financial institution. Corrections must be made within 60-days following the statement of account.
    
    Note: There is no charge for bank drafts. Applications received by the end of the month will be set for draft on the 10th of the immediately following month. All new bank draft applicants will have the noted account prenoted prior to the actual draft occurring. This may show up as a $0 draft on your bank statement. This is the method the Town uses to verify correct account information before the first draft occurs. This authorization is non-negotiable and non-transferable
22. Confirmation
    Please initial to agree that you verify that the above information is correct and accurate to the best of your knowledge and that you also understand and agree with the content/stipulations listed.
24. Initials*
26. When you sign up for auto draft from your checking account you qualify for the monthly drawing!

    Each month the Town holds a drawing to pay the water bill of one customer enrolled in automatic bank draft (up to $75). 

    Complete this form and submit or call Customer Service at (704) 455-5614 to enroll in auto draft: you could be next month’s winner!

    Click here to learn more.

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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field