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CUSTOMER
SIGNATURE
NAME OF SPOUSE
NAME
ACCT. #
SERVICE ADDRESS D D(0, S Vef
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This applicatton hereby request and authorizes the Utility to render water and/or sewage disposal
services to the premises described above in accordance with the Utilities present or future rates,
rules end regulations, which by reference are made a part of this contract. Applicant agrees to pay
the Utility promptly for such services in accordance with the established rules and regulations.
CUSTOMERS DEPOSITS ARE NON NEGOTIABLE OR TRANSFERABLE.
SOCIAL SEC/
FED ID
SPOUSE SOCIAL SEC.
OFFICE USE ONLY a
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