Application for Property Owners
 (Renters may not use this form)

  
     
 

*Effective Date:              -- mm/dd/yy *No. in Household  
*Social Security No.:   License No.:  
*Customer Name:   Spouse Name:
*Address to be Served:  
Address (cont.):
*City:  
*State:  
*Zip/Postal Code  
Home Phone:   Emergency Phone:
E-mail
   
Different Mailing Address:
Mail. Address (cont.):
City:
State:
Zip/Postal Code
Employed By:   Work Phone:  
Comments or Other Info:  
AS Applicant I Hereby Agree To Be Legally Responsible For Any And All Bills
Incurred For The Address Above While In My Name.
Typing your  Full Name below signifies your agreement with all terms of service.
 
*"Signature":   *Sign.Date:   -- mm/dd/yy

* - Required information

ATTENTION DELINQUENT PROPERTY OWNERS!

After Two (2) Cut Offs For Non-Payment, You Will Be Required To Pay A
$75.00 Deposit Before Service Is Reconnected.

Georgetown Municipal Water & Sewer Service
P.O. Box 640 • Georgetown, KY • 40324 • (502) 863-7816 • FAX (502) 863-2471

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