New Customer Account Form

Applicant Name (required)

Service Address (required)

City (required)

Zip Code (required)

Mailing Address (required)

City (required)

Zip Code (required)

Phone Number (required)

Cell Phone Number (required)

Please select one

Owner

Tenant

Realtor

Management Company

Tentative Move In Date (required)

In consideration for receiving Water Service from Belfair Water District #1 at the above location, I hereby acknowledge responsibility for payment at service billings. A non-refundable application fee of forty dollars($40) will be required at the time of submitting your application, as an owner. Water accounts are billed monthly, and payments are due on the 28th of every month to prevent interruption of service. You are responsible for water service until your account is closed. Belfair Water District #1 is not responsible for water damage to this property or its contents. If the water is off, it may take up to two(2) business days to have service restored. In consideration for having water service initiated/restored at the above address, I agree to ensure that all water service facilities ( sink, tub, faucets inside/outside, toilets, etc.) are turned off; or that someone will be on the property to check for leakages. We recommend that you turn off your private shut off valve, if applicable. Thank you!

By typing my name below, I am electronically signing this application (required)

Date (required)

IN ADDITION TO NEW CUSTOMER ACCOUNT FORM PLEASE COMPLETE THE CROSS CONNECTION CONTROL SURVEY, THANK YOU!

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