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CUSTOMER
SIGNATURE
NAME OF SPOUSE
SCANNED
BY
St. Lucie County
—1-771
ST. LUCIE COUNTY UTILITIES - P.O. BOX 728. FT. PIERCE. FL 34982
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NAME -)
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SERVICE ADDRESS
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SUBDIVISION IC�LP �I\L`l�P
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LOT BLOCK
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BILLINGADDRESS
0716Z\ \ 3
PHONE # S 6% —
MOVE IN/CLOSING DATE NVLL r i
This application 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 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 NONNEGOTIABLE OR TRANSFERABLE. —
SOCIAL SEC/ "" k.
FED ID L17 1 I�G F,' LJI (.
SPOUSE SOCIAL
OFFICE USE ONLY I
DATE RECEIVEDaIP CASH CHK #\ (� RECEIVED