New Customer Application - Shoal Creek

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SHOAL CREEK ACCOUNT APPLICATION

Application below is hereby made to the Coweta County Water and Sewerage Authority to supply water and/or sewer service. The applicant agrees to take and pay for service according to the Terms and Conditions of the Authority at the described property as shown on this application. The applicant further agrees to give prompt written notice to the Authority in the event the applicant desires to discontinue service(s). Failure to do so will render applicant liable to the Authority for all water charges assessed against the subject premises until such time as actual written notice is received by the Authority.

Activation Fee: $75 (will show on your first bill)

Account Type*

Customer Service Line Material*

Have you had service with us before? If so, what was your previous service address?

Account Holder*

First Name

Middle Name (optional)

Last Name

Account Holder's Date of Birth*

Social Security Number*

No dashes

Company Name*

Federal ID Number*

XX-XXXXXXX

Point of Contact (Name & Number)

Email*

Would you like to sign up for paperless statements?*

Yes No (Paper statements will incur a fee of $2.50/statement beginning in 2023.)

Please note there is a $2.50 fee for each paper statement mailed.

Phone Number*

Employer*

Work Phone

Secondary Account Holder's Name*

First Name

Middle Name (optional)

Last Name

Secondary Account Holder's Date of Birth*

Secondary Account Holder's Social Security Number*

No dashes

Secondary Account Holder's E-mail*

Secondary Account Holder's Phone Number*

Secondary Account Holder's Employer*

Secondary Account Holder's Work Phone

Service Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Billing Address (Where you want your bill sent)

Address Line 1

Address Line 2

City

State

ZIP Code

Would you like to add an Authorized User to this account?

Yes No

Authorized user to access account (not account holder)*

First Name

Last Name

Last four of authorized user's social security number*

XXXX

Applicant Description*

Owner Tenant Landlord

Do you own a swimming pool ?*

Yes No

Please review the Backflow Prevention Program Customer Responsibilities, located here.

I have read and understand the backflow prevention requirements*

Please review ourLeak Coverage Program and Leak Adjustment Policy.

I have read and agree to the Leak Coverage Program and Policy*

I agree

Leak Coverage assists customers who receive a large bill due to a water leak. If you choose to opt-out and have a leak, you will be responsible for the FULL amount of your bill.

Submit Proof of Residence/Occupancy*

No File Chosen

File uploads may not work on some mobile devices.

If renting, please provide lease agreement. If the Coweta County tax assessor website shows that you are the owner, you may use the tax assessment form on the bottom of the tax assessor page as your proof of ownership.

Submit Identification of person completing this form (typically driver's license). *

No File Chosen

File uploads may not work on some mobile devices.

We only need the front side of your license.

Submit Identification of Secondary Account Holder (typically driver's license). *

No File Chosen

File uploads may not work on some mobile devices.

We only need the front side of your license.

ACKNOWLEDGEMENT*

Closing Document/Purchase Agreement Lease/Rental Agreement Property Tax Bill Property Deed

Proof of occupancy/residency is AT LEAST one of the above. Please contact 770-254-3710

By submitting this application you agree that you have read the Terms and Conditions as well as understand your responsibilities incurred by your request for water or water/sewer service. Furthermore you understand the rate structure for water or water/sewer. You also understand that you will be responsible for any and all cost associated with the recovery from any delinquent accounts, including but not limited to reasonable attorney's fees and costs for collection or with a collection agency.

Please read information about Drought Restrictions.

By submitting this application, you agree to this policy.

I have read and understand the terms and conditions*

Signature of the Individual Completing this Form*

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Sign your name above using your mouse, stylus or finger

Date*

Additional Information