Application for Water, Sewer & Garbage Service

Application for Water, Sewer & Garbage Service

Residential Account Deposit: $216.00_Monthly Fees: $108.00
DATE SERVICE IS REQUESTED*

MonthDayYear
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please read and initial
initials* I understand that payment for water/sewer service is required in full by the 15th of each month.
initials* I also understand that my service may be disconnected for non-payment if my account is more than 60 days late.
initials* I also agree to pay a $20.00 disconnect fee and a $20.00 reconnect fee if my water/sewer service is disconnected.

APPLICANT DATA RECORD

Please provide the following information so that the City of Hendrum will be in compliance with title VI of the Civil Rights Act of 1964.

In order to met the requirements of the Federal Register Vol. 62 No. 210, Revision to the Standards for the Classification of Federal Data on Race Ethnicity, all application forms for city utility connections must include below the signature and date block the following disclosure statements.

"The following information is requested by the Federal Government in order to monitor compliance with the Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note race/national origin of individual applicants on the basis of visual observation or surname".

The City of Hendrum is an Equal Opportunity Provider and Employer
RACIAL CATEGORIES

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhite
ETHNIC CATEGORIES

Hispanic or LatinoNot Hispanic or Latino
If you feel you have been discriminated against: To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TTD).
Signature*

Clear
Today's Date*

MonthDayYear
Date
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