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2. Service Address*
   Address for the new water/sewer account
4. Date Service is to Begin*
   Date Service is to Begin
   Date you want your water/sewer service account to start
6. Name*
7. Email Address*
9. Address*
11. City
12. State
13. Zip Code
15. Phone Number*
17. Property Owner's Name (if different than above)
    Please provide property owners name/contact information.
18. Property Owner's Contact Information
    Please provide the property owner's mailing address, email address and phone number. Owner will need to sign the form if the property is rented.
20. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
22. Electronic Signature
24. Final Steps Required
    When form is completed please print and bring to the Town Office with a current photo ID, Social Security number and a check for the $35.00 Administrative Fee. Please call the Town Office at (540) 687-5152 if renting to find out additional steps needed to apply and deposit amounts required.
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25. Print Only

* indicates a required field