Wells Branch MUD - Crossroads Service Application

Wells Branch MUD
Water and Wastewater Service Application

Wells Branch MUD
C/O Crossroads Utility Services
2601 Forest Creek Drive
Round Rock, Texas 78665-1232
customerservice@crossroadsus.com
512-246-1400
Service Address*

Street Address

Unit number or letter

CityState

Zip Code
Requested Start Date*

MonthDayYear
Applications take 1-2 business days to process. Same day services are offered for an additional cost. Please call 512-246-1400 to request same day service after submitting your application.
Applicant Legal Name*

First Name (or Business Name)Last Name (Put N/A if Business)
Applicant is Owner/Renter/Property Manager*
Property Manager: Enter TAX ID Number*
A copy of your W9 and executed client contract may be requested.
Applicant Date of Birth*

MonthDayYear
Date
Applicant Billing Address - where do you want your bills or notices mailed*

Street Address

Unit number or letter

CityState

Zip Code
Applicant Email Address*
example@example.com
Applicant Phone Number*
Secondary Phone Number
Applicant Driver's License Number & State*
Or Government Issued Identification Number
Government Identification

Please upload a copy of a valid Government Issued ID
Cancelof
Take Photo of Government Identification
The undersigned hereby makes application to Wells Branch MUD for water and wastewater services. I understand and agree that I will be responsible for all water and wastewater services provided to the property described in this application until such time as service to the property is disconnected in accordance with the District's Rules and Regulations regarding utility services. I agree to comply with the Districts's Rules and Regulations and to pay for all utility services rendered to the property in a timely manner and understand that a violation of the Rules and Regulations may result in a penalty and/or termination of utility services to my/our property. I represent that the information above is true and correct.
Signed*

Clear
Printed Name*
Would you like to add another Applicant? (Optional)*

YesNo

Co-Applicant Information
Co-Applicant Legal Name*

First NameLast Name
Co-Applicant Date of Birth*

MonthDayYear
Date
Co-Applicant Email Address*
example@example.com
Co-Applicant Phone Number*
Co-Applicant Driver's License Number & State*
Or Government Issued Identification Number
Co-Applicant Government Identification

Please upload a copy of a valid Government Issued ID
Cancelof
Take Photo of Government Identification
The undersigned hereby makes application to Wells Branch MUD for water and wastewater services. I understand and agree that I will be responsible for all water and wastewater services provided to the property described in this application until such time as service to the property is disconnected in accordance with the District's Rules and Regulations regarding utility services. I agree to comply with the District's Rules and Regulations and to pay for all utility services rendered to the property in a timely manner and understand that a violation of the Rules and Regulations may result in a penalty and/or termination of utility services to my/our property. I represent that the information above is true and correct.
Signed Co-Applicant*

Clear
Co-Applicant Printed Name*

Billing Preferences
How would you like your bills to be delivered?*

Paper statementE-bill StatementPaper and E-bill statement
Confidentiality Request
House Bill 872 requires a government-operated utility may not disclose personal information in a customer’s account record, or any information relating to the volume of units of usage or amounts billed on the account unless the customer requests that the government-operated utility disclose the information. By agreeing to service with the utility and signing below, you agree to have your information kept confidential with the government operated utility. A customer may request disclosure of their information by delivering to the government-operated a written request.
Decline Confidentiality (only select this box if you do NOT want your information confidential)

I do NOT want my information kept confidential.

Customer Service Agreement
Terms and Conditions
By submitting this form I agree to all of the following Terms and Conditions.*

I understand my district may require 1-2 business days to connect service.I understand I will be contacted once my application is processed with deposit and application fee information that will need to be paid in full prior to connection of service.I understand that I am responsible for all discharges of water on the customer side of the water meter, regardless if that discharge was a result of my actions or in-actions.I understand that a minimum monthly service charge will be assessed for my active utility account regardless of water consumption.I understand that I am liable for any damage to the water meter installed on the property. It is unlawful for anyone to break, damage, tamper with, obstruct or prevent the proper operation of the water meter.I understand that any of the offenses listed above will result in additional fees for water lost, damages incurred, and criminal charges may be filed against the customer.I agree, both applicant and co-applicant, if applicable, have the authority to close the account and that the return of the deposit, if any, may be issued to the applicant and/or co-applicant.I consent to receiving SMS text message alerts from my district related to emergency water or sewer repairs or outages that may affect my services. The notices are sent from 833-237-2606 or 512-246-1400 and I can opt out of these messages by replying STOP to these notices at any time.
Signed*

Clear
Printed Name*
Signed Co-Applicant

Clear
Co-Applicant Printed Name
Date*

MonthDayYear
Date
Should be Empty:

Co-Applicant Information

Billing Preferences

Confidentiality Request

Customer Service Agreement

Terms and Conditions