HomeMy WebLinkAboutNEW CUSTOMER APPLICATION�
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WATER COMM
SEWER � RES
METER SZ. M/F
II2R
$ SECURITY DEP
SERVICE FEE
SAME DAY FEE
OVERTIME FEE
METER INSTALL.'
CFC/WATER
l FPUA CFC
J � � CFC/SEWER
GUAR. REV.
$��]j�� LATERAL
/ � "" TOTAL
CUSTOMER
SIGNATURE
NAME OF SPOUSE
NAME �l V /
ACCT. #
SERVICE
SUBDIVISION_L
BILLEQGADDRESS.
LZ
�JJ'��
�� Y' t/
PHONE # �` - I I / ��-[ �� MOVE IN/�/OSING DATE
�s�. �cv I�J+,�(lvjybcJ� F�wjn��lYi•C! �r/a" (JY,I�{t�
�-¢— � �0.1Ve ab4 ufPeietYA
This application here y request and authonzes the tiE y to ren er water and/or sewage disposal
services to the premises described above is accordance with the Utilities present or future rates,
riles and 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/ a�j _� /' / / ��
FED ID � jj '7�/r Y" (o
SPOUSE SOCIAL
_ OFFICE USE ONLY
DATE RECEIVED CASH CHK # RECEIVED BY
WATER COMM
SEWER � � RES
METER SZ. M/F
IRR
$ SECURITY DEP
SERVICE FEE
SAME DAY FEE
OVERTIME FEE
METER INSTALL.
CFC/WATER
FPUA CFC
• �� CFC/SEWER
GUAR. REV.
LATFRAT.
s� � � roTAL
CUSTOMER
SIGNATURE
NAME OF SPOUSE
NAME
ACCT. #
SERVICE
��S CLG
SUBDIVISION SUh f/ LOT�BLOCK
BII,LING ADDRE/S,S `/ V K-//l �TL, l v`-e�
PxoNE tl V(r! 11 / 7
use-�o,c.�(r-EtiC�w�ger �� nax1e Ilk+le �o�r �q�I,,J�hyl�fyC�(v�rpcfi u a��.-
This application hereby requesl and au[ oie Utility to render w�er�9n ors age disposal
services to the premises described above in accordance with the Utilities present or future rates,
rules and regulations, which by reference are made a part of this contract. Applicant agrees [o pay
the Utility promptly for such services in accordance with the established rules and regulations.
CUSTOMERS DEPOSITS ARE NON NEGOTIABLE OR TRANSFERABLE.
FED ID SEC/ <JO ' �Y� `TIO JV
SPOUSE SOCIAI, SEC.
It .
USE ONLY �
_ Oi�i4# l�l- _ RECEIVED BY
:IE UTILITIES DEP
0 VIRGINA AVE
PIERCE, FL 34992
W,n:17
XX 488 TID'.
XXXXX501
:REDIT CARD
VISA SALE
XXXXXXXXXXXX2341
26
1695
26
03525G
Manual
Online
$0,00
M
T
$1900,25
pay above total amount
to card'nsuer agreement,
p muit if Credit Voucher)
1ERCNANT COPY'
ST LUCIE Ul.UITIES DEP
2300 VIRGINA AVE
FORT PIERCE, FL 34982
U$�012021 14:3034
9ID', XXXXXXXXXKXX488 TID', XXXXX501
CREDIT CARD
VISA SALE
cud a XXXXXXXXXXXX2341
EQ V. 25
F<itrla V. 1695
INVOICE 25
4proval Code'. 01044G
Erihy Method: manual
Mi de' Online
74ix Amount:
aad Code: M
S; LE AMOUNT $1900025
i agree ro pay above total amount
according to card Issuer agreement,
(Merchant agreement It Credit Voucher)
MERGNANT COPY