SANITARY BOARD OF BLUEFIELD SEWER APPLICATION

SANITARY BOARD OF BLUEFIELD

Application For Wastewater/Sewer
The Sanitary Board of Bluefield

P.O. Box 1870

Bluefield WV 24701

Phone: (304) 325-3681
Water Account Number
Water Service Provider

WV American WaterTown of Bluefield VABluewell PSDTazewell County PSA
Date to Start Service*

MonthDayYear
Date
Customer Name*
Cell Phone*
Email Address*

Confirmation EmailConfirm Email
Home Phone
Would you be interested in receiving your bill by email?*

YesNo
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from Service Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Last 4*
Drivers License/State ID*
Have you/your spouse ever had service with The Sanitary Board of Bluefield?

YesNo
Do you Rent this Property?

YesNo
Landlords Name
Landlords Phone
By signing below, I hereby authorize service to be established in my name at the above property location and agree to pay for service and abide by The Sanitary Board of Bluefield rules until service is discontinued. I understand that thisapplication is accepted subject to the availability of service at this location.
Applicants Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: