Form

Water Service Application

Please complete the following form if you are RENTING or LEASING the property.
Applicant's Name *

First Name Last Name

Service Address *


Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Service Start Date *

- Month - Day Year

Billing Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail *
Phone Number *

- Area Code Phone Number
Name of Rental Agency or Landlord *
Rental Agency or Landlord Phone Number or Email
Lease Start Date *

- Month - Day Year
Lease End Date *

- Month - Day Year
Have You Had Water Service With Park Water Company Before? *

No Yes
Previous Service Address *
Additional Information
By sending this agreement, the customer agrees to the following:
1. The Company shall not be responsible for the maintenance and operation of the customer's pipes and facilities. The customer agrees not to utilize any appliance or device which is not properly constructed, controlled and protected or which may adversely affect the water service; the Company reserves the right to discontinue or withhold water service to such apparatus or device.
2. The Company may refuse to discontinue water service rendered under application made by any member or agent of a household, organization, or business for any reason contained in Rule 25-30.320, Florida Administration Code. Any unauthorized connections to the customer's water service shall be subject to immediate discontinuance without notice, in accordance with Rule 25-30.320, Florida Administrative Code.
3. The customer agrees to abide by all existing Company rules and regulations as constrained in the tariff.
4. Bills for water service will be rendered monthly as stated in the rate schedule. Bills must be paid within 20 days of mailing bills. If payment is not made after 5 working days written notice, service may be discontinued.
5. When a customer wishes to terminate service on any premises where water and/or wastewater service is supplied by the Company, the Company may require (oral, written) notice within 5 days prior to the date customer desires to terminate service.
Enter the message as it's shown *
IMPORTANT INFORMATION

After Sending the Customer Agreement, Park Water Company requires the proper forms and payments to be submitted prior to new service starting.

A copy of your lease* must be presented. It can be emailed to ParkWaterCo@aol.com, by either you or your landlord. Copy of lease must be received prior to service being started at property. (*The main lease page(s) we need is the one showing the lease/rental dates, the name(s) on the lease and your landlord’s name. If that is all on the first page, just send one page)

A $15 Service Charge and $60 Deposit must be paid prior to service starting. Check or Money Order Payments Only, made out to Park Water Company. Please write service address on payment.

Payment/Lease can be mailed or placed in our drop box located at 25 1st Ave N.
Should be Empty:

Water Service Application