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Multi-Family Residential - Outside City

Application for Water Services ONLY

SERVICE LOCATION INFORMATION

Service Address - Street, Apt/Ste
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Service Address - City, State, Zip Code
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Requested Service Start Date (no weekends, holidays or backdated start service dates):
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APPLICANT INFORMATION

First Name:

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Last Name:

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Mailing Address - Street, Apt/Ste
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Mailing Address - City, State, Zip Code
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Primary Phone:
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Alternate Phone:
E-mail:
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ID - Document type
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ID - Document Number
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ID - Issued by (State or Country)

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Previous Service Address with SCMU
Which low-income assistance programs do you or a member of your household participate in?
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Which low-income assistance programs do you or a member of your household participate in?
I DECLARE UNDER PENALTY OF PERJURY THAT 1) I AM THE RESPONSIBLE PARTY AT THE SERVICE ADDRESS AND/OR AN AUTHORIZED REPRESENTATIVE OF THE BUSINESS, AND 2) THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT. I ACCEPT RESPONSIBILITY FOR THIS UTILITY SERVICE AND AGREE TO ABIDE BY ALL RULES AND REGULATIONS ESTABLISHED BY THE CITY COUNCIL GOVERNING UTILITIES.
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