WATER APPLICATION7 by 4K9bV7S8

VIEWS: 2 PAGES: 1

									                                                   Town of McIntosh
                                                        Water Application
                                                 P. O. Box 165, McIntosh, FL 32664
                                           Town Office (352) 591-1047     Fax (352) 591-1947
                                              Email: d.gonano.mcintosh@windstream.net
                                                          www.townofmcintosh.org


Date: _____________________
                                              To be completed by Town Clerk:
                                                 Account Number: ________
Applicant Name: ___________________________________________________
Mailing Address: ___________________________________________________
                  __________________________________________________
Physical Address: __________________________________________________
Phone (Home):     ___________________________________
      (Cell):    ____________________________________
      (Email):   ____________________________________
Do you have a medical or other condition requiring immediate notification in
the event a “Boil Water Notification” is necessary? Otherwise, the Marion
County Call Communicator will timely call each water customer on file.
                                Yes / No

Is water currently on?                           YES    /    NO
Date service is to begin:                        _____________

Deposit Amount:                         $60.00
Plus: Service Fee                        10.00
       Total                            $70.00

Customer comments or instructions:
_____________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
             Please note: Water bill includes Water & Garbage. You may not elect to opt out of the garbage fee.

                                                              _______________________________
                                                              Accepted: Applicant’s Signature
____________
For Office Use

								
To top