Tap No.____ Acct No.____ Service Start Date____________________
1. Owner’s Name:___________________________________________
2. Renter Name (If applicable)__________________________________
3. Service Address:___________________________________________
4. Owner Billing Address:______________________________________
5. Renter Billing Address:_____________________________________
6. Residential Service_____ or Commercial Service_____ (Check One)
7. Home Phone:_________________ Work Phone:_________________
8. Garbage Service Requested: Please circle Cart Two Cans One Can Other
9. I hereby make application to have a water service connection at the above
service address, subject to the rules and regulations of the City of Tekoa.
I understand that the water connection and water deposit fees (if applicable)
will be paid in full prior to the water connection. I also understand that I must
make a formal request to terminate this water connection. This is done by
completing the bottom section of this form. The person signing this form
will be responsible for payment of the water service until the termination
request is signed.
_________________________________________ _____________________
Signature of Owner Date
_________________________________________ _____________________
Signature of Renter (if applicable) Date
REQUEST FOR SERVICE TERMINATION
I request that the water service be terminated to the above mentioned address on:
Date______________ Signature____________________________________