HomeMy WebLinkAboutUtility Company Approval `UTILITIES DEP ,.. ST LU 71E,COU.NTY WATER & SEWER DISTRICT (SLCU)
2300 VIRGINA AVE
FORT PIERCE,FL 34982 „ ;;:: NEW CUSTOMER APPLICATION
St.
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11-1 CREDIT CARD
MC SALE
4 FORT Card a XXXXXXXXXW6337 NAME-Ye ��.0 C`c « —AC�Ila G
FL Chip Card: Mastercard
3498
7�ID; AOOD0000041010 ACCT.#
Amou SEQ#: 3
Amou. Batch ft; 1766 j
INVOICE 3 ! SERVICE ADDRESS�` �� �J .��L LCpl.
Char 7ppioval Code: 01267P
Thar Entry Method: Chip Read
Mode: Issuer
User L- LOT i� BLOCK
SUBDIVISION -
`ALE AMOUNT $521.25 j r>
�STAL.. BILLING ADDRESS'>t' /C� �) i `� l ; ��C" _�t^ I ✓ �1
CUSTOMER'COPY TR EMAIL ADDRESS'y_— n)Q(D')
PHONE,#)` C7r� MOVE IN/CLOSING DATE
CFC/SEWER
GUAR. REV. This application hereby requests 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 and `
LATERAL regulations,which by reference are made a part of this contract.Applicant agrees to pay Utility promptly for
$ TOTAL such services in accordance with the established rules.and regulations.
CUSTOMERS DEPOSITS ARE NON NEGOTIABLE OR TRANSFERABLE.
APPLICANT AGREES THAT APPLICANT WILL BEGIN PAYING BASE FACILITY CHARGES .FOR THE UTII.,ITY SERVICE
APPLIED FOR ON THE DAY THE, WATER METER OR OTHER UTILITY SERVICE CONNECTION IS INSTALLED, AT,,
APPLICANT'S PROPERTY,REGARDLESS OF WHEN APPLICANT-STARTS UTILIZING THE METER AND/OR SERVICE:
CUSTOMER SIGNATURE SOCIAL SEC/FED.ID_�&
NAME OF SPOUSE SPOUSE SOCIAL
OFFICE USE ONLY /J
DATE RECEIVED.. /� ? � CASH -C-d-fR�t�#� W��- RECEIVED BY ' t