Application For Connection

""
1

Old North State Water Company, LLC

PO Box 10127 

Birmingham, AL 35202

Applicant #1:
Applicant #2:
Applicant Role:
Mailing Address
Service Address
Subdivision Name
Information Applicant #1
Contact Phone #:
Information Applicant #2
Contact Phone #:
Email:
Old North State Water Company, LLC is prohibited from disclosure of any personal information except as may be required by a Court of Law
Date to Start Service
date_range

Customer Agreement (Owner)

As the owner, I hereby accept responsibility for all charges pertaining to water / waste water service and will not compromise the proper operation of water / waste water sanitary sewer being provided in any manner. I understand that any unpaid balance may result in service being discontinued.

Customer Agreement (Tenant) ​

As the tenant, I hereby accept responsibility for all charges pertaining to waste water service and will not compromise the proper operation of waste water sanitary sewer being provided in any manner. I understand that any unpaid balance may result in service being discontinued.

I am a
Owner / Tenant Signature
Date
date_range
Previous
Next
FormCraft - WordPress form builder