Public Water/Sewer Eligibility Application

Applicant Information

Location of Property:

Specify use of meter

If residence, specify how many in household:

If development, specify how many:

If business/commercial, specify estimated number of gallons of water to be used daily:

(meter size determined by usage)

Please indicate CDIB Information. It will help in receiving grants for system improvements.

CDIB Indian Card?

If Yes, CDIB:

Member Signature & Statement

The undersigned hereby applies to:

for membership and for water service, and hereby agrees, that upon approval hereof, I/We will comply with and be bound by all Rules and Regulations of:

and agree to pay all fees, assessments, and other lawful amounts chargeable to the member.

For OFFICE Use Only

PUBLIC WATER

PUBLIC SEWER (If Applicable)