APPLICATION FOR SERVICE
LIMITED LIABILITY CORPORATION

This is an application for

Applicant is


Address Where Service Will Be Established

Address
City
State
Zip -
Date Service Required
Limited Liability Corporation Name
Type of Business
DBA
E-Mail Address


Mailing Address (If Different Than Service Address)

Address Line 1
Address Line 2
Suite/Apt
City
State
Zip -
Business Phone Number ..



List Primary Officers

Name Residence Address Title Emergency Contact
Number


Deposit requirement subject to credit review or incomplete credit application.  Social security number and driver's license number are used only for identification on customer contracts.

If a deposit is required on your account, it shall equal the average of two (2) monthly billings which will be shown on your monthly statement. You may be asked for an additional deposit if the actual consumption exceeds this estimate.

PLEASE READ THE AGREEMENT SET OUT BELOW

The Applicant certifies that he/she is the owner-lessee-tenant of the premises where service is applied for with lawful authority to sign for this application of Utility service and agrees to pay the applicable rates and abide by the terms and conditions as prescribed by Municipal Ordinance and Utility Tariff for all present and future Utility service.  Acceptance of this application by the Municipality for the collection of any unpaid accounts shall be paid by the applicant. The conditions under which a deposit will be required or waived are set forth in Water and Wastewater Tariffs.  I hereby declare that the information provided is true, accurate, and completed to the best of my knowledge and belief, and is voluntarily submitted for the purpose of receiving Utility service.  It is understood that upon presentation this application becomes the property of the Municipality.  I also certify that I am eighteen (18) years of age or older.

NAME OF APPLICANT COMPLETING THIS FORM




Applicant's Title



Applicant's Daytime Telephone Number ..

Remarks



After you submit this application, you should receive a confirmation page.  If the confirmation page does not display, that means an error occurred.  Please report the error to AWWU Customer Service at 564-2700.