Agreement for Utility Services

I hereby request utility services at the below listed location and agree to pay for all sewer and sanitation services used, delivered or made available at this location until I notify the City in writing to discontinue such services.  I agree that all utility services will be delivered subject to the terms and provisions of the Ordinances of the City of Menan as they now exist or may be generally amended from time to time.  I UNDERSTAND THE CITY MAKES NO WARRANTIES OF ANY KIND AND ALL WARRANTIES, WHETHER EXPRESSED OR IMPLIED INCLUDING ALL WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, ARE EXPRESSLY DISCLAIMED.  I represent that I am either the owner of the premises described below or am leasing the property from the owner.  I also represent that neither I nor any member of my household have a delinquent utility account with the City.

Requestor:
Address Service will be provided to:
Date Service Starts:
Garbage Service:   Yes     No

Billing Address:
 
If you would like a statement via email, please provide your email address:
Email:
Telephone Number:

Please check one:   Owner     Leasing (Renting)
If leasing, please provide the following:
Name of Owner:
Address:
 
Telephone Number:

Security Code