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    Water Sewer Trash App

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    Tre Tre
    Imvu

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Water Sewer Trash App

    Uploaded by

    Tre Tre
    33 views1 page
    Imvu

    Original Title

    WATER SEWER TRASH APP

    Copyright

    © © All Rights Reserved

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    Imvu

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    33 views1 page

    Water Sewer Trash App

    Uploaded by

    Tre Tre
    Imvu

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Application Water/Sewer/Trash Service

    ACCOUNT # DATE

    Name: ____________________________________ Name: ________________________________________


    Email: ____________________________________ Email: ________________________________________
    SS#: ______________________________________ SS#: __________________________________________
    Date of Birth: _____________________________ Date of Birth: _________________________________
    Drivers License#:__________________________ Drivers License#: _____________________________
    Primary Phone: ____________________________ Primary Phone: _______________________________
    Secondary Phone: __________________________ Secondary Phone: _____________________________

    RENT OWN DEPOSIT AMOUNT: $___________ SERVICE CHARGE: $__________

    TAP FEE: $______________ OCCUPANCY PERMIT NUMBER: _____________


    City of Collinsville, Illinois

    I, ____________________________, hereby make application for water to be turned on at the following


    address, ______________________________ effective _____/_____/_____ and agree to pay within 28 days
    of the billing date, or a 10% penalty will be assessed per rates established by City Ordinance. The
    water will be DISCONNECTED if the account is not paid within the specified time (after one bill past
    due). The undersigned hereby guarantees payment of all bills contracted above from date until
    notice to the contrary is received by the City of Collinsville.
    **APPLICANT SIGNATURE: ______________________________________________________________________

    MAILING ADDRESS - (If different from service address)


    Name: ___________________________________________________________________________________________
    __________________________________________________________________________________________________
    Street or Apartment City State Zip

    PRIOR ADDRESS:
    __________________________________________________________________________________________________
    Street or Apartment City State Zip

    Present Employer:
    Company Name: ________________________________________________________________________________
    Phone: ___________________________________ Name of Supervisor: _________________________________
    Source of Income if not employed: _______________________________________________________________

    PROOF OF RESIDENCY - Landlord Information


    Landlord Name: ________________________________________________ Phone: _______________________
    _________________________________________________________________________________________________
    Street or Apartment City State Zip

    I swear that the information provided on this application is true to the best of my knowledge:

    __________________________________________________________________________________________________
    **APPLICANT SIGNATURE

    City of Collinsville, Illinois • 125 South Center Street • 618-346-5200

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