Village Of Kelliher Utility & Waste Collection Disconnection Application

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Utility Account No.: *

Disconnection Date *

YYYY

Name (First and Last): *

Civic Street Address: *

Mailing Address: *

City: *

Province: *

Postal Code: *

Email Address: *

Phone (Home): *

Phone (Cell): *

Meter Deposit should be: *

Applied to a current account

Transferred to a new account

Refunded to applicant

Note: If the property will be unoccupied, we recommend that water lines be blown out and winterized after disconnection to help prevent possible damage due to freezing. The Village of Kelliher will not accept responsibility for frozen lines past the curb stop.

By completing this form, you acknowledge that you are responsible for the completeness and accuracy of the information you provide. Any false or misleading statement with respect to this form may result in the denying of your application and refusal of service. All personal information provided on this form is collected by the Village of Kelliher for the purpose of determining entitlement of the applicant for the provision of services described herein. In the performance of those services, the personal information is collected, used, and disclosed under the Authority of Access to Information and Protection of Privacy Act and any other provincial laws, regulations, and policies applicable to the protection of personal information. By submitting this form the applicant consents to the collection, use, and disclosure of personal information by the Village of Kelliher for the provision of services. This acknowledgement shall be governed and constructed in accordance with the laws of Saskatchewan. *

I Accept

Date this form was filled out: *

YYYY

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