Location #:

 Acct #:

  Applied Date:

 Own: Rent:

 *Name:

  Phone:

 

 Cell: Home: Work:

 * Service Address:

 Mailing Address:

 *Date Service Required:

 *DL #:

Application Fee : $ Deposit Amount : $ Other Charges: : $

Membership Fee (Non-refundable) : $ Meter Reinstall/New Install: $

  Total Paid:    Paid By: Check     Cash

Upon receipt of the required deposit, plus, any necessary service fees from the above, and establishing the obligation to follow the rules of Zellwood Water Users, Inc. including the Cross Connection Control (“CCC”) program, the Company shall furnish water to the above address. The Applicant agrees to comply with all Company Policies & Procedures and Company Bylaws as amended from time to time (current Policies & Procedures and Bylaws are available online at the company website: https://zellwoodwater.com). The Applicant understands that compliance with the Company Policies & Procedures is a prerequisite to receipt of water service from the Company. The Applicant is responsible for familiarizing himself/herself with all of the Policies & Procedures of the Company to avoid disconnection charges or fines. The failure of an Applicant to pay water charges shall result in the following, regardless of personal circumstances:

A.Bills are payable when produced and due on the date shown on the bill. Bills are delinquent after the due date, atwhich time a late charge of $20.00, will be applied to the current charge.

B.In the event an Applicant is disconnected two times in any 24-month period for nonpayment, the Company shallrequire an immediate doubling of the current deposit.

C.Nonpayment of bill and late charge(s) for a period of forty-five days from the payable date will result indisconnection of service. A nonpayment fee will be added if not paid in full prior to the disconnect date.

D.Nonpayment of the bill, late charge and nonpayment fee from (c) above extending for ninety days after theoriginal payable date may result in the Company, in addition to all other rights and remedies, canceling the Owner'smembership by removal of water meter, further resulting in the Applicant losing entitlement to receive water fromthe Company, and an additional substantial charge for reinstallation of the meter.

  Initial      Please Note: An added $20.00 monthly billing Capital Improvement Charge for system upgrades toour aged system was voted on by the General Membership in October 2015.

  Initial      Payment on all accounts is due by the 20th of each month. Past Due accounts will only receive a Second Notice of cutoff with date due by mail. No other notice will be sent out. There is a reconnection fee of $50.00 if water is interrupted for nonpayment. Total balance amount on account is due before reconnection.

  Initial      I am aware of the Policies & Procedures, have read this Application, and agree with these terms of service.

  * Electronic Signature:

Enter Security Code