Start/Stop Service Form

I, the undersigned, hereby contract for water service from the mains of the Kennebec Water District for:

Service Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address

Same as service address

Street Address Address Line 2 City State ZIP Code

Requested Start Date of Service*

I am the building ...*

Landlord's Name*

First Last

Landlord's Address*

Street Address Address Line 2 City State ZIP Code

Landlord's Phone*

Is this a rental unit/property?*

How many units?*

Type of Service*

Does the building have a swimming pool?*

We use this information when evaluating whether someone has a leak at their property.

If building is fully or partially commercial, what type of business is this?

If building is fully or partially commercial, what is the business' name?

Is this a new building or will there be substantial renovations to the existing building?*

Customer Contact and Identification Information

Phone*

Email*

Driver's License Number*

Photo/Scan of Driver's License*

Accepted file types: jpg, png, gif, pdf, jpeg, Max. file size: 4 MB.

Federal Tax ID Number*

Attach Federal Tax ID Form or Driver's License*

Max. file size: 50 MB.

Real Estate/Closing Agent ( Name & Agency )

Have you ever been a Kennebec Water District customer? If so, list previous address(es).*

I, the undersigned, agree to abide by the Terms and Conditions of service of the District now in force or which may hereafter be ordered or approved by the Maine Public Utilities Commission.

I further agree to be responsible for all payments for water services at the premises described above at rates now in force or which may be hereafter ordered or approved by the Maine Public Utilities Commission. Payments for such service shall be made by the undersigned until service is terminated.

I, the undersigned, agree that all the information provided on this document is accurate and truthful. Failure to provide accurate information of the intentional falsification of information may result in denial of water service and/or referral to the appropriate law enforcement agency.

Hidden

Applicant's Name*

First Last

Applicant Name(s)*

Applicant Digital Signature(s)*

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