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Residential Water Account Form

2. Type of Service:*

   (CHECK ONLY ONE)

   1. NEW ACCOUNT/SERVICE

   1. TRANSFER SERVICE

   1. RE-CONNECT SERVICE

   1. DISCONNECT SERVICE
4. Date*
5. Turn on Date
7. Name*
8. Date of Birth*
10. Drivers License Number*
11. State*
13. Social Security Number*
    Please ONLY type in the LAST 4 Digits of your Social Security Number.
15. Service Address*
17. Type*

    1. Rent

    1. Own
19. Mailing Address*
21. City*
22. State*
23. Zip Code*
25. Home Phone Number*
26. Employer Name
28. Work Phone Number
30. Landlord Name
31. Landlord Phone
33. Signature*
    Please type in your FULL NAME.
34. E-mail Address
    Please Enter Your E-mail Address.
36. Attachment: Current Photo ID
    Please Attach: Current Photo ID OR Current Drivers License ID
38. Attachment: Rental/Lease Agreement
    If you are renting the home/property please attach a copy of your rental agreement/lease.
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field