Application for Water Service
Date:_________________
Subject always to the established rates, rules and regulations and any changes or amendments hereafter made.
I, the undersigned __Owner __Tenant of the property at ________________________ Hereby make application for a supply of water at said premises with service to begin_______________. And to continue until cancelled by at least ten days written notice. If I sublet, I will be responsible for any water and sewer charges left unpaid by tenants of the property listed above.
Approved:
| The Municipal Authority of the Borough of Derry | Owner_______________________ Print Name ___________________
|
| Per________________________ | Tenant_______________________ Print Name ___________________ |
| Mail bill to: ________________________ _________________________ |
|
* Please Print and return to the Main office at: 620 N. Chestnut St. Derry, PA 15627
The Municipal Authority of the Borough of Derry is an equal opportunity service provider.
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