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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