New Resident Water, Sewer, and Refuse contract

Name * Required
First Last
Co-applicant name
First Last
if applicable
Email * Required
Phone * Required
Residential status * Required
Date of occupancy - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Service Address * Required
Street Address Address Line 2
Mailing address
Street Address Address Line 2 City State ZIP Code

If different than service address.
Number of occupants
Have you had service in West Milton before? * Required
- Yes
- No
Address of previous service.
Street Address Address Line 2
Year of previous service
Refuse
- Standard Volume- $24.10 monthly
- Low Volume- $22.20 monthly
Please choose which works best for your home.
Consent * Required
I agree to follow the rules, regulations, and ordinances.
Subject to the Rules and Regulations governing the systems of the Municipality of West Milton, Ohio, and all Ordinances and Laws pertaining thereto, now in force or which shall later become in force, the undersigned hereby makes application for water to be turned on for use at the premises known on the records of the Department of Service. Furthermore, mandatory refuse and recycling is in effect and it is required of all residential units to utilize the residential permittee for refuse and recycling needs. Service WILL BE DISCONTINUED if any charges are not paid by the date reflected on the SHUTOFF NOTICE. (The Municipality, by law, cannot excuse customers from prompt payment of charges.) An "off and on" charge will be charged to have service restored. In as much as all charges reflect to the property and preference to the owners. I/We agree to notify the Municipality of West Milton immediately upon the completion of any change in ownership or title on the property in question.
Today's Date - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
CAPTCHA