NEW SERVICE APPLICATION
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PRIMARY APPLICANT'S NAME *
PHOTO ID #, SOCIAL SECURITY #, OR DRIVER'S LICENSE # *
PHONE # *
TYPE OF PHONE *
SECONDARY APPLICANT'S NAME
PHOTO ID #, SOCIAL SECURITY #, OR DRIVER'S LICENSE #
PHONE #
TYPE OF PHONE
Clear selection
CONTACT PERSON (OTHER THAN YOURSELF) *
CONTACT PERSON'S PHONE # *
TYPE OF PHONE *
SERVICE ADDRESS *
DATE YOU WOULD LIKE SERVICE TO BEGIN *
MM
/
DD
/
YYYY
BILLING ADDRESS *
WOULD YOU LIKE TO RECEIVE YOUR MONTHLY BILL BY EMAIL OR PAPER BILL? *
DO YOU RENT OR OWN THE HOME? *
OWNER'S NAME (IF YOU RENT)
OWNER'S PHONE # (IF YOU RENT)
NUMBER OF PEOPLE IN THE HOUSEHOLD *
DO YOU CURRENTLY HAVE SERVICE WITH US (GREENSBURG MUNICIPAL WATER & WASTEWATER) AT ANOTHER LOCATION? *
IF YES, WHAT IS THE ADDRESS?
IF YES, WHAT DATE WOULD YOU LIKE THAT SERVICE TO END? IF YOU DO NOT WANT TO END YOUR CURRENT SERVICE, PLEASE RESPOND WITH N/A.
ADDITIONAL COMMENTS
By signing this application (in person or authorizing by phone, fax, email, or electronic signature) the primary & secondary applicant agree to pay and be responsible for all water, wastewater & sanitation charges, regardless if consumption is used. Charges start on the date specified and end on the date specified by the consumer (by phone, in person, fax or email) or, if the account appears on the disconnect list the 2nd consecutive month.  In the event there is a secondary applicant, they will have equal responsibility for said charges.  If the primary or secondary applicant wish to be removed from their account they must phone this office with a date to have their name removed and provide an address & phone number for any future correspondence.  Deposits will remain with the account until both applicants have vacated the service address.  If a final bill has been left unpaid, the remaining name(s) on the account bear total responsibility.  Any past due balances must be paid before a new service will be activated. Any balance from a previous location will be transferred to your new location.  The consumer will be responsible for any litigation expense incurred in collecting bad debt.  Interest will not be paid on deposits.  Bills are due the 17th of each month.  Failure to receive bill does not excuse payment.  A form from our office that has been signed by the owner must be provided for any rental property prior to the service start date. 1" and 5/8" meters are owned by the GMWW and cannot be tampered with.  Any consumer found turning on/off their own meter may be prosecuted and will be responsible for replacing the meter if damaged. Phone 812.663.5621 if you have a leak, or after hours at 812.663.2641.  **If you have City trash service, you are responsible for your trash bin.  Your account will be charged $85.00 if the bin is missing upon closing your account.** *
APPLICANT'S SIGNATURE *
SECONDARY APPLICANT'S SIGNATURE
EMAIL ADDRESS *
Submit
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