Customer Information Form ACCOUNT # DATE LOCATION OF SERVICE OWNER NAME (As listed on grant deed) CONTACT NAME (If owner is business or trust) PHONE MAILING ADDRESS CITY STATE ZIP E-MAIL ADDRESS CO-OWNER (If any) NAME PHONE MAILING ADDRESS CITY STATE ZIP E-MAIL ADDRESS PERSON TO NOTIFY IN CASE OF EMERGENCY NAME DAYTIME PHONE EVENING PHONE ANY ADDITIONAL INFORMATION PLEASE COMPLETE AND SIGN THIS FORM. ALL OWNERS OF PROPERTY MUST BE LISTED. SECURITY DEPOSIT OF $100.00 (CASH OR CHECK) MUST BE SUBMITTED TO OFFICE. PLEASE NOTE: If service is discontinued for any reason, including a change in ownership, there will be an additional $100.00 turn on fee. We bill bi-monthly. The statements are sent out on the last business day of the month. Payment is due by the 20th of the following month. A 10% late charge is assessed on the overdue amount not timely paid. By signing, or authorizing the signing of this form, the owner agrees to observe all district regulations now, or hereafter adopted, relating to water and sewer service and to pay bills promptly. The water and sewer laterals serving your property may be required to have backflow preventers and backwater valves. You are responsible for ensuring these devices are properly installed and maintained. The District is not responsible for damage from service backups caused by the absence of these devices or the failure to maintain these devices. I HAVE READ AND AGREE TO ABIDE BY THESE TERMS AND CONDITIONS. IF PARTNERSHIP, OR CO-OWNER, TWO SIGNATURES ARE REQUIRED. DATE Your Signature (required) Confirm e-Signature Review Electronic Records and Signatures Policy (required)Read our Electronic Record and Signature Disclosure I agree to use electronic records and signatures There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
