Application for the Supply of Water

Application for the Supply of Water
Between
First Name*
Middle Name
Last Name*
Hereinafter called the "Consumer"
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone
Cell Phone*
Date of Birth*
Drivers License*
Email
AND
TOWN OF KINDERSLEY
Hereinafter called the "Town"
Subject to the printed rules and regulations recited on the reverse of this agreement, which rules and regulations are accepted as forming part of this agreement, the Town of Kindersley is hereby requested to make necessary connections for the supply of water to the:*
Possession Date*
MM slash DD slash YYYY
Located at (Civic Address):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
The consumer agrees to use the said water from the time at which connection is made and to pay therefore to the office of the Town, within thirty (30) days of the date of any bill issued, the amount charged as calculated by the reading of the water meter from time to time, and the consumer hereby authorizes and allows the Town to set up in a convenient and suitable place on the above premises, the necessary meter(s) and appliance(s).

Water is to be charged for on the basis of meter measurement, and the consumer agrees to be responsible for the water used until written notice to discontinue the supply is received by the Town, and all sums of money due by the consumer to the Town are paid. The rates charged for water supplied to the consumer are to be established by the Town and are subject to change without notice.
The consumer hereby agrees to pay to the Town with this application the sum of
$
the receipt of which is hereby acknowledged, which sum shall be retained by the Town as, and by way of, a meter deposit which shall be repayable to the consumer upon the termination of this agreement, subject always to all or any sum that may be due and payable by the consumer to the Town.

This agreement shall not be binding upon either part until accepted by the Administrator of the Town of Kindersley and duly signed by him/her or an employee duly authorized to sign on his/her behalf.
Billing Options (Select One)*
Consumer Signature*

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Application for the Supply of Water

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