Verde Lakes Water Corporation Residential Application For Service

Account#
For Verde Lakes Accounting Use Only
Verde Lakes Water Corporation Residential Application For Service
The following information is being requested for the purpose of opening an account to provide and bill for utility service.

46.00 Refundable Security Deposit

30.00 Service Establishment Fee
REQUESTED TURN ON DATE

MonthDayYear
Date
TODAY’S DATE

MonthDayYear
Date
Applicant Information
APPLICANT’S NAME
SERVICE ADDRESS
MAILING ADDRESS
PHONE
Format: (000) 000-0000.
EMAIL
example@example.com
DOB
Property Owner Information
PROPERTY OWNERSHIP
PROPERTY OWNER’S NAME
PROPERTY OWNER’S PHONE
Format: (000) 000-0000.
Emergency Contact Information
EMERGENCY CONTACT NAME
EMERGENCY CONTACT PHONE
Format: (000) 000-0000.
Payment Information
AMT DUE
3.5% ONLINE FEE

USDA 3.5% Fee is Required

I understand I am responsible for prompt payment of all charges at the above service address, in addition to collection fees for any unpaid balance. I agree to abide by present and future rates, regulations, policies and procedures for water services.

Verde Lakes Water Corporation is not responsible for leaks or water damage that occurs to property on the customer's side of the meter. Customer is responsible to have a customer valve on their side of the meter for their use. Customer will be held responsible for any damage that occurs to Verde Lake Water Corporation's meter, valve, meter box, or service line that services customer's property. I have read and agree to all conditions in the above statement.
SIGNATURE:
Sign Here
Date

MonthDayYear
Date
If paying with cash or check, please print and return the form to Verde Lakes Water
2867 S VERDE LAKES DR STE B CAMP VERDE AZ 86322
Should be Empty: