NJCPSD Water/Sewer Application

NORTHERN JACKSON COUNTY PUBLIC SERVICE DISTRICT

APPLICATION FOR WATER/SEWER SERVICE

39 Gilmore Drive Sandyville WV 25275 Phone 304-273-9621
PROPERTY ADDRESS FOR SERVICE (Including City, State, Zip)
If previous customer, when/where?
TYPE OF SERVICE:
DATE TO ACTIVATE SERVICE

MonthDayYear
Date
PROPERTY OWNER
PROPERTY OWNER PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
APPLICANT NAME
APPLICANT PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
APPLICANT FORMER ADDRESS (Including City, State, Zip)
APPLICANT EMPLOYER/SOURCE OF INCOME
APPLICANT EMPLOYER PHONE
Please enter a valid phone number.Format: (000) 000-0000.
APPLICANT EMERGENCY CONTACT
APPLICANT EMERGENCY CONTACT PHONE
Please enter a valid phone number.Format: (000) 000-0000.
CO-APPLICANT NAME
CO-APPLICANT PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
CO-APPLICANT FORMER ADDRESS (Including City, State, Zip)
CO-APPLICANT EMPLOYER/SOURCE OF INCOME
CO-APPLICANT EMPLOYER PHONE
Please enter a valid phone number.Format: (000) 000-0000.
CO-APPLICANT EMERGENCY CONTACT
CO-APPLICANT EMERGENCY CONTACT PHONE
Please enter a valid phone number.Format: (000) 000-0000.
PRIMARY CONTACT NAME
PRIMARY CONTACT PHONE
Please enter a valid phone number.Format: (000) 000-0000.
PRIMARY CONTACT MAILING ADDRESS
I acknowledge that I am responsible for the payment of the NJCPSD services applied for and confirm that the information given in this application is true to the best of my knowledge and that false representation of this application will lead to all NJCPSD services being discontinue with proper notice. I assume responsibility of the account/services listed until I notify the NJCPSD of my discontinuance of services in writing. I give my permission for NJCPSD to speak with emergency contact listed.
APPLICANT SIGNATURE
Date

MonthDayYear
Date
APPLICANT'S PHOTO ID

Cancelof
CO-APPLICANT SIGNATURE
Date

MonthDayYear
Date
CO-APPLICANT'S PHOTO ID

Cancelof
Email
example@example.com
Should be Empty: