NEWWATER CUSTOMER

Transcript

1 TOWN OF FARMVILLE New Water/Sewer Customer Form Location# ________________ CIF # ___________ Customer # _ ________________ Name: _________________________________________________ DOB : ___________ Driver’s license # _________________ __________________________________ SSN #: Location address: ___________________________________________________________ Mailing address: ___________________________________________________________ _____________ _________________________________________ Student’s Home address: Phone number: Work number: _______________________ _________________________ ______________________________________________________________ Email address: Cut on Date : _ ____________ Deposit Date: ____________ T oday’s date: __________ Deposit Amounts: Residential or $150.00 / Commercial $ 200.00 or $ 300.00 $100.00 (In Town) (Out of Town) (In Town) (Out of Town) I certify that I am the l egal owne r/rente r/property manager of the property located at __________________________. I acknowledge that I am legally responsible for the payment of this bill and agree that the of limitation shall statute not bar ef any balance here under. forts to collect S : _____________________________________ Date: ____________ ignature ___________________________________________________ NAME OF LANDLORD: ∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞ By signing this form, I agree to be at this location _ ___________________________Between the hours of 1:00 pm an 2:00 pm on ___________________________. I Understand that if I am not at his address when the meter reader turns the water meter on and the meter is turning, indicating water being used; the meter will be turned back off. Should this occur, the water meter will be turned on the following business day between the times of 1:00 pm and 2:00 pm. Signed: _______________________________________ Date: ______________________ ∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞∞ I hereby request that the Town of Farmville turn the water on at the following address: ___________________________________. I understand that the Town of Farmville prefers someone be at this address when the water is turned on. I will not be able to be at this address when the water is turned on; therefore I will not hold the Town Of Farmville responsible for any damages resulting from the act of turning water on at the above stated location of this date: ______________________. Signed: _______________________________________ Date: ________________________ Office use only: ________________ Entered by: ____________________ Checked By: _

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