CONTRACT FOR SERVICE WITH THE CITY OF HOLDENVILLE
 

DATE___________________    PHONE_________________________

WATER CERTIFICATE_________________

NAME OF RESPONSIBLE PARTY_______________________________________________
                                                           First             Middle                Maiden                        Last

SS# OR DL#_________________________ DATE OF BIRTH_______________________

SERVICE ADDRESS___________________________________________________________

MAILING ADDRESS___________________________________________________________

EMPLOYER____________________________   PHONE______________________________

ADDRESS_____________________________________________________________________

SPOUSE OR CO-OCCUPANT___________________________________________________

SS# OR DL#_________________________ DATE OF BIRTH_______________________

EMPLOYER________________________ PHONE________________________________

ADDRESS_____________________________________________________________________

PERSONAL REFERENCE_________________________ PHONE___________________

ADDRESS___________________________________     RELATIONSHIP_______________

HAVE YOU EVER HAD SERVICE WITH THE CITY BEFORE?_____________________

IF SO, WHAT ADDRESS?_______________________________________________________

NAME OF PROPERTY OWNER AT ADDRESS YOU WISH TO HAVE SERVICE AT:

________________________________________________ PHONE___________________

ANY CUSTOMER LEAVING THE CITY OF HOLDENVILLE WITH A BAD DEBT WILL BE SUBJECT TO A HIGHER DEPOSIT.

I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS AND CERTIFY THAT THEY ARE TRUE AND COMPLETE.

SIGNATURE OF (APPLICANT) RESPONSIBLE PARTY___________________________