Pine Island Community Development District

WATER AND WASTEWATER UTILITIES POLICY MANUAL

CUSTOMER SERVICE APPLICATION FORM

THIS SECTION IS FOR DISTRICT PERSONNEL USE ONLY

Application Date	Time	AM/PM	
Application Fee Paid: $	Connection Fees Paid: $	AFPI Charges Paid: $___________	
Date Paid:	Date Paid:	Date Paid:	
Check #:	Check #:	Check #:	
Grinder Pump Fee Paid: $	Meter Install Fees Paid: $________	Water Meter Size: _____________	
Date Paid:	Date Paid:	Irrigation Meter Size: __________	
Check #:	Check #:	Lot Acreage: _________________	

TOTAL AMOUNT DUE: $

District Account # Given:

Anticipated Service Turn On Date:

Name of Person Taking Application:

Name of Person Receiving Payment:

Service Address:	_____________________

Lot # or Legal Description (If No Address):	_______________________

Applicant Info: (If a Business Please Provide Information for Authorized Representatives)

Name of Applicant:					
Name of Authorized Representative:				
Billing Address:			City/State:	Zip:	
Telephone Numbers: Work:	______	Home:		Cell:	

Drivers License Number (or)

Social Security Number (or)

Other I.D. ( If above not available)

Name of Employer:	_____________________		
Employer Address:		City/State:	Zip:	
Employer Telephone:	______			
Previous Home Address:		City/State:	Zip:	
How Long at Previous Address?	Yrs.	Months		

If there is anyone other than yourself who is authorized to be contacted and/or make decisions concerning utility service please list this person(s) name, their relationship (relative, employee, etc.) to you, and their contact numbers.

Name:	______

Relationship:

Contact #s:	Wk	Hm	Cell

In the event of an emergency, planned service interruption or discontinuance of service for nonpayment, is there anyone you wish to be contacted should the District not be able to contact you for any reason? If so, please list the emergency contact’s name, their relationship to you and their contact numbers:

Revised Date:  December 13, 2012	33

Pine Island Community Development District

WATER AND WASTEWATER UTILITIES POLICY MANUAL

Name:	______

Relationship:

Contact #s:	Wk	Hm	Cell

If the service address is a rental property, below please provide the name of the owner, the owners address and contact number

Owner Name:	______

Owner Address:	______
_	_____

_____

Contact #s: ___________________Wk_____________________Hm____________________Cell

NOTE: The Customer or authorized representative of a Customer must be present when service is turned on. This requirement is to help prevent possible water damage from faucets, etc. accidentally left in the open position. If District personnel are unable to turn the water on because of water registering at the meter and you or your authorized representative were not present at the initiation of service, additional charges may be applied to your account for rescheduling at another time. Additionally, when service is turned on, please have the District’s personnel point out the location of the Shut-Off Valve and remember the location of same for your future use. Below, please indicate the best time to establish service when someone will be present at the service address which time the District will endeavor but not guarantee to accommodate:
_____________________________.

PROSPECTIVE CUSTOMERS ARE ADVISED THAT IN ADDITION TO A MONTHLY USAGE FEE FOR WATER, WASTEWATER AND/OR IRRIGATION QUALITY WATER SERVICE, THERE MAY BE ADDITIONAL FEES CHARGED TO ESTABLISH A UTILITY CONNECTION TO THE SERVICE ADDRESS, TO INSTALL A METER BOX AT THE SERVICE ADDRESS, AND OTHER CHARGES AND FEES IMPOSED IN CONNECTION WITH OTHER MISCELLANEOUS SERVICES PROVIDED BY THE DISTRICT WHICH SHALL BE BILLED AND PAID IN ACCORDANCE WITH THE ‘WATER UTILITIES POLICY MANUAL’ ADOPTED BY THE DISTRICT’S BOARD OF SUPERVISORS. A COPY OF THIS MANUAL SHOULD BE PROVIDED UPON PAYMENT OF THE APPLICATION FEE AND SHOULD BE READ AND UNDERSTOOD FULLY BEFORE ENGAGING THE DISTRICT’S UTILITY SERVICES.

APPLICANT’S SIGNATURE: _________________________________________________

CO-APPLICANT’S SIGNATURE: ______________________________________________

If Married Spouse must sign as Co- Applicant

Revised Date:  December 13, 2012	34