APPLICATION FOR SERVICE
RESIDENTIAL

This is an application for

Applicant is

Number of Units

Applicant Information

Last Name
First Name
Middle Initial
Social Security Number (optional) --
Driver's License Number  State
Employer
Home Telephone Number ..
Work Telephone Number ..
Daytime Telephone Number ..
E-Mail Address


Address Where Service Will Be Established

Address
City
State
Zip -
Date Service Required


Mailing Address (If Different Than Service Address)

Address Line 1
Address Line 2
Suite/Apt
City
State
Zip -



Spouse's Name
   
Name of Nearest Relative Not Living With You
Relationship
Address Line 1
Address Line 2
Suite/Apt
City
State
Zip -
Telephone Number ..



Handicapped, Elderly at Location

Type of Life Support (if any)

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




Relationship to the Person Applying for Service



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.