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SATSUMA WATER AND SEWER DEPARTMENT

NEW CUSTOMER INFORMATION SHEET

NAME: _______________________________________

SERVICE ADDRESS: _____________________________

MAILING ADDRESS: ____________________________

PHONE NUMBER: HOME ________________________

CELL NUMBER: ________________________________

CARRIER (IF WANTING TEXTS) ____________________

OTHER NUMBERS: _____________________________

LAST FOUR DIGITS OF SS#: _______________________

DRIVERS LICENSE NUMBER: ______________________

EMAIL ADDRESS: _______________________________

Check here if you would like to receive your bill in email format. NO PAPER BILL WILL BE MAILED

Please check any of the following options for how you

would like to be notified in case of emergency:

phone call email text message

Deposits will be refunded after a request to discontinue

service has been made by the customer and there is a zero

balance on the account.

Water Turn-On Liability Release By signing below,

you acknowledge you are at least 18 years of age and

accept full responsibility for the above address for said

water service to be connected. In accepting this responsibility,

you release the Satsuma Water and Sewer Board from any

damages that may occur from the initiation of water service

at the above address.

SIGNATURE: _______________________DATE: _______________






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