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PICKENS COUNTY WATER & SEWER AUTHORITY Service Connection Date: 1266 EAST CHURCH STREET; SUITE 117; JASPER, GA 30143 PHONE: [PHONE REDACTED] FAX: [PHONE REDACTED] Please provide a valid driver’s license or valid ID and proof of ownership of property and/or renter/lease agreement with application. APPLICANT: CO-APPLICANT: CONTACT PHONE#(s): SERVICE (911) ADDRESS: BILLING ADDRESS: EMERGENCY CONTACT: PHONE#: OWN: RENT: PROPERTY OWNER (IF APPLICABLE): TYPE OF SERVICE: (HOUSE) (MOBILE HOME) (OTHER) DIRECTIONS TO PROPERTY & A BRIEF BUILDING DESCRIPTION: “The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in the program. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note in the race/national origin of individual applicants on the basis of visual Observation of surname. White, not of Hispanic origin Hispanic Black, not of Hispanic origin Asian or Pacific Islander American Indian Alaskan Native “This is an Equal Opportunity Program. Discrimination is prohibited by Federal Law. Complaints of discrimination may be filed with USDA, Director, Office of Civil Rights, Room 326-W, Whitten Bldg., 1400 Independence Ave, SW, Washington, D.C. 20205-9410.” BY SIGNING THIS LEGAL DOCUMENT WITH PICKENS COUNTY WATER & SEWER AUTHORITY, I/WE AGREE TO PAY THE FULL AMOUNT OF WATER REGISTERED THROUGH THE METER BY THE 15TH OF EACH MONTH. I/WE UNDERSTAND THAT IF NOT PAID BY THE 15TH OF THE MONTH THE BALANCE DUE IS CONSIDERED PAST DUE AND IF NOT PAID BY THE LAST BUSINESS DAY OF THE MONTH, IS SUBJECT TO DISCONNECTION WITHOUT NOTICE. *BY SIGNING THIS LEGAL DOCUMENT WITH PICKENS COUNTY WATER AND SEWER AUTHORITY, I/WE UNDERSTAND AND AGREE THAT ANY CREDIT GRANTED SHALL BE PAID IN ACCORDANCE WITH THE TERMS AND AGREEMENTS, THAT THE CREDIT GRANTOR MAY ADD ONE AND ONE HALF PERCENT (1 AND PER MONTH TO ANY BALANCE OWED AND IN THE EVENT OF DEFAULT TO PAY REASONABLE COLLECTION CHARGES AND/OR ATTORNEY FEES. BY SIGNING THIS CONTRACT, I/WE ARE BOUND TO THE ORIGINAL CONTRACT SET FORTH FOR THIS PROPERTY. EMAILED BILL CONSENT: EMAIL ADDRESS: I GIVE MY CONSENT FOR MY UTILITY BILL TO BE SENT BY EMAIL. I ACKNOWLEDGE IT IS MY RESPONSIBILITY TO UPDATE THE WATER OFFICE OF ANY CHANGES IN MY EMAIL ADDRESS. I AGREE THAT WITH THIS OPTION I WILL NOT RECEIVE A PAPER COPY OF MY WATER BILL. I UNDERSTAND THAT I’LL NEED TO ADD PICKENS COUNTY WATER TO MY APPROVED SENDERS LIST IF SPAM FILTERS ARE USED FOR EMAIL. *SIGNATURE OF APPLICANT: DATE: *SIGNATURE OF CO-APPLICANT: DATE: FOR OFFICE USE ONLY ACCOUNT # DATE ON: METER#: BEGINNING READING: FINAL BILLING ADDRESS: FINAL READING: DATE OFF: ADIMINISTRATIVE CLERK: SIGN SIGN