APPLICATION FOR SERVICE

APPLICATION FOR SERVICE
City of Logan Water Department
DEPOSIT MUST BE PAID BEFORE SERVICE IS CONNECTED $50-WATER $50-SEWER (IF APPLICABLE)

YOU CAN ONLY PAY DEPOSIT OVER THE PHONE OR IN PERSON
LOCATION*
DEPOSIT*
DATE*

MonthDayYear
Date
Water OnlySewer OnlyWater and Sewer OnlySprinkler Fee
ResidentialCommercial
Yes
If so where?
Yes
CUSTOMER NAME*
MAILING ADDRESS*
PHYSICAL ADDRESS*
LAST 4 OF SS*
FEIN
PHONE #*
Format: (000) 000-0000.
EMAIL ADDRESS
example@example.com
I DO NOT HAVE AN EMAIL ADDRESSPREFER NOT TO SHARE MY EMAIL ADDRESS
RENTOWN
IF RENT PROPERTY OWNERS NAME
OWNERS MAILING ADDRESS
OWNER'S PHONE
Format: (000) 000-0000.
PREVIOUS OCCUPANT
Format: (000) 000-0000.
PREVIOUS OCCUPANT
NUMBER IN HOUSEHOLD
NAMES OF ADULTS
MARRIEDSINGLEDIVORCED
SPOUSES MAIDEN NAME
I HEREBY AUTHORIZE SERVICE TO BE ESTABLISHED IN MY NAME AT THE ABOVE PROPERTY LOCATION AND AGREE TO PAY FOR SERVICE UNTIL DISCONTINUED BY MY REQUEST IN WRITING. I UNDERSTAND THAT THIS APPLICATION IS ACCEPTED SUBJECT TO THE AVAILABILITY OF SERVICE AT THIS LOCATION. I AFFIRM THAT ALL INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT.
APPLICANTS SIGNATURE*
DATE*

MonthDayYear
Date

City of Logan Water Department