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ST. UCIE.COUNTY UTILITIES-P.O:BOX.728 FT.PIERCE FL 34482
RES NAME 1U ho
'MIF
MR . ACCT.#.
' SECURITY DEP 'SERVICE ADDRESS �(� �1
SERVICE FEE
SAME DAY FEE , '� `
SUBDIVISION �/ , � LOT a BLOCK
BILLING ADDRES I
OVERTIME FEE Ste61(4
METER INSTALL.'
CFC/WATER - `Ym
FPUA CFC ' 'PHONE# c 17 't( S MOVE IN/CLOSING DATE
CFC/SEWER
GUAR:REV. This application hereby request and authorises the Utility to render water and/or sewage disposal
services-to the premises described above in accordancewith the Utilities.present or'future rates,
LATERAL rules and regulations,which by reference are made apart of this contract.Applicant agrees to pay
the Utilityt promptly for such services in accordance with the established rules and regulations.
$ " TOTAL 'CUSTOMERS DEPOSITSARE NON NEGOTIABLE'OR TRANSFERABLE.
CUSTOMER SOCIALS t L!
SIGNATURE FED ID 59077
r
NAME OF SPOUSE SPOUSE SOCIAL SEC.
OFFICE USE ONLY
DATE RECEIVED CAS CHK# RECEIVED BYAM
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