Customer Information Form

THIS FORM MUST BE COMPLETED BEFORE SERVICE WILL BEGIN. OUTSTANDING BALANCES FROM YOUR PREVIOUS ACCOUNTS WILL BE TRANSFERRED TO YOUR NEW ACCOUNT

Date

Phone

Name

Social Security Number (LAST 4 DIGITS)

Email Address

Name of All Adults at Service Address

Service Address

Have you had water service with us before?

No

Yes

If Yes, Service Address

---

Current Employer Information

Employer

Address

Telephone

Supervisor

---

Emergency Contact (In case a leak is detected and we are unable to contact you)

Name / Relationship

Phone

Name / Relationship

Phone

---

I guarantee that all information given above is true and correct

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Date

There was a problem saving your submission. Please try again later.

Please wait while your submission is being saved...

Submitting...Submit

Thank you, your submission has been received.

There are severe penalties for giving false information. Please verify that the above information is correct