CITY OF SHOSHONE APPLICATION FOR WATER, SEWER, & GARBAGE SERVICES DATE OF APPLICATION:__________________________________________
PROPERTY ADDRESS:____________________________________________ PROPERTY DESCRIPTION:________________________________________
DATE OF OCCUPANCY:___________________________________________ NAME OF PERSON TO BE BILLED:_________________________________
MAILING ADDRESS:______________________________________________
___________________________________________
TELEPHONE:_____________________________________________________ NAME OF SPOUSE AND/OR OTHER OCCUPANTS (exclude children):
_________________________________ _____________________________ NAME OF NEAREST RELATIVE: (other than spouse)
_________________________________________________________________ ADDRESS OF NEAREST RELATIVE:_________________________________
EMPLOYER'S NAME:______________________________________________ EMPLOYER'S ADDRESS:___________________________________________
EMPLOYER'S PHONE NUMBER:____________________________________ In any event if any sewer charge or water service charge shall not be paid by the 10th
day of the month after which said services have been rendered and have been billed, then water service shall be discontinued for the premises until full payment of the dual charges, deposits $124.00, disconnection fee of $10.00 and reconnection fee of $10 are paid in full.
I hereby certify that I have read the foregoing termination notice and that I understand it fully. _______________________________ APPLICANT
_______________________________ SOCIAL SECURITY NUMBER
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