Application for Water Service

Account # Customer # Date of Application

Date Service Requested By

Service Address Apt # Lot # Type: Class: Status:

Customer Information:

Company Name (If Applicable) Federal ID #: Tax Exempt #: Customer Name: Maiden Name (within last 10 years): Drivers Lic # State SSN Date of Birth

Email Address Cell Phone Number Home Phone Number Work Phone Number Previous Reedsburg Utility Customer?

Spouse / 2nd Responsible Party

Name of Applicant Maiden Name (within last 10 years) Drivers Lic # State SSN Date of Birth

Email Address Cell Phone Number Home Phone Number Work Phone Number Previous Reedsburg Utility Customer?

Billing / Previous Address

Billing Address (If Different than Service) City State Zip Code Previous Address

Only fill out the following section if you rent this location:

Name of Landlord Landlord Phone Number Landlord Address

The undersigned warrants that the information on this application is true, and provided without intentional omission.

Date:

Applicant Signature 2nd Applicant Signature Landlord Signature (If applicable)

Important: Reedsburg Utility requires positive identification and/or a service deposit as allowed by the Wisconsin Public Service Commission. Before service can be furnished, this application must be completed in full and submitted to Reedsburg Utility Commission. Missing and incomplete information will delay service. A copy of the building permit must be provided as well as payment of applicable fees prior to service connection.

Plumbing Statement / Information

The Plumber states that all plumbing performed under this permit at this service location is in compliance with the State Plumbing Code of Wisconsin. The Plumber further represents that all meter settings have been properly marked and identified in situations involving multiple meters.

Date:

Plumbers Name: Plumbers Company: Plumbers Address: Plumbers Phone Number: Building Permit: Signature of Plumber or Owner