Request Service Application

Applicant Name(Required)

First Last

Phone Number(Required)

Spouse's Name (if applicable)

First Last

Spouse's Phone Number

Property Address(Required)

Street Address Address Line 2 City State ZIP Code

County(Required)

Email(Required)

Plans for the Property(Required)

Legal Description of Property(Required)

New Service - Deposit $200 + Tap install $750 + Connection Fee = Total cost $ 990. Reconnect (If tap is present) - Deposit $200 + Reconnect $40 = Total cost $240 ** If road bore is required, the cost will be determined by a contractor per job (to be bid) **

Customer Signature(Required)

Use your finger or mouse to sign this agreement. Please note that electronic signatures are binding

The following information is requested by the federal government in order to monitor compliance with federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.

White, non-Hispanic

Black, non-Hispanic

American Indian/Alaskan Native

Hispanic

Asian/Pacific Islander

Other

Gender

Male

Female