Application for Water Service – Charlevoix Township

Application for Water Service

Name

First Last

Service Connection Address

Street Address City State / Province / Region ZIP / Postal Code

Contact Phone #

Is Service Connection Address The Same As Billing Address?

Yes

No

Billing Address

Street Address City State / Province / Region ZIP / Postal Code

If Different From Service Connection Address

Service Size Requested - Select One

Amount Paid

Signature of Official Accepting Application

Date