Acct #:

 Location #:

 Date:

 Own: Rent:

 *Physical Address:

 *Name:

 Mailing Address:

 City, State, Zip:

 Home Phone:

 Work Phone:

 Cell Phone:

 *DL #:

 *E-mail:

Do you want to receive your billing statement by e-mail? Yes No

Application Fee ($50.00): Check     Cash     Amount:

Deposit Amount ($175.00): Check     Cash     Amount:

Membership Fee ($50.00)
Note: (Non-refundable) Check     Cash     Amount:

New Service Hookup Fee
(per Individual Inspection): Check     Cash     Amount:

 Total:

  Initial      Please note: An added $20.00 monthly billing Capital Improvement charge for system upgrades to our aged system was voted on by the General Membership in October 2015.

Payment on all accounts is due by the 20th of each month. Past Due accounts will only receive a Second Notice of cut-off with date due by mail. No other notice will be sent out. There is a reconnection fee of $25.00 if water is interrupted for nonpayment. Total balance amount on account is due before reconnection.

  * Electronic Signature:

Enter Security Code