LOCK HAVEN CITY WATER DEPARTMENT

APPLICATIONS FOR WATER SERVICE

DATE: _______________________

I HEREBY REQUEST WATER SERVICE BE MADE IN MY NAME AT THE FOLLOWING

ADDRESS: _____________________________________ NUMBER OF UNITS ___________

SERVICE NEEDED: ______________________

THE APPLICANT HEREBY AGREES TO ABIDE BY THE RULES AND REGULATIONS OF THE LOCK HAVEN WATER DEPARTMENT, AND TO PAY FOR ALL WATER WHICH HE OR SHE CONSUMED UNDER THE RATE SCHEDULES CURRENTLY IN EFFECT AND AS AMENDED IN THE FUTURE, UNTIL NOTICE IS GIVEN TO THE WATER DEPARTMENT TO DISCONTINUE SERVICE TO THIS ACCOUNT.

CUSTOMER’S NAME: _______________________________________ OWNER / TENANT

ACCOUNT NUMBER ____________________

OWNER’S NAME: ___________________________________________

OWNER’S PHONE NUMBER __________________________________

SIGNATURE OF CUSTOMER ___________________________________________________

ADDRESS FOR BILLING (If different from above)

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