Water Utility Service Request

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Please complete and submit the following form:

Please correct the field(s) marked in red below:

Company Name

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Company Address

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Company Phone Number

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Company Contact Name

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Contact Phone Number

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Email Address

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Subdivision Name

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Lot Number

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Building Permit Number

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Service Address

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Water Meter

Water Meter
THE UNDERSIGNED WILL GRANT THE COMPANY THE NECESSARY RIGHTS, PRIVILEGES AND EASEMENTS TO CONSTRUCT, OPERATE, REPLACE, REPAIR AND PERPETUALLY MAINTAIN ON THE TRANSMISSION OR DISTRIBUTION OF COMMUNICATION AND WILL EXECUTE AND PROPOSE FOR ANY OF THEM.  ALL SERVICE LINES SUPPLYING THE UNDERSIGNED WITH COMMUNICATIONS AND ALL INSTRUMENTALITIES AND OTHER APPLIANCES AND EQUIPMENT CONSTRUCTED OR INSTALLED BY THE COMPANY ON SAID PROPERTY, EXCEPT SO MUCH THEREOF, IF ANY AS SHALL BE PAID FOR BY THE UNDERSIGNED, SHALL AT ALL TIMES BE THE SOLE PROPERTY OF THE COMPANY AND THE COMPANY SHALL HAVE THE RIGHT OF ACCESS TO SAID PROPERTY TO REPAIR AND SERVICE AND UPON DISCONTINUANCE OF SERVICE FOR ANY REASON TO MOVE THE SAME.  APPLICANT AGREES TO PAY COLLECTION EXPENSES OF THE COMPANY INCLUDING REASONABLE ATTORNEYS FEES, IF ACCOUNT BECOMES DELINQUENT.  SUBJECT AT ALL TIMES TO LAWFUL RATES AND REGULATIONS.  APPLICANT AGREES TO COMPLY WITH THE BY-LAWS, ARTICLES AND POLICIES OF INCORPORATION OF SAID ASSOCIATION AFFIXED.

Signature

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Date

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