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Form updated 9/2019 Page 1 City of Woodburn Application for Water/Sewer Service SERVICE ADDRESS: Apt/Unit/Suite SERVICE REQUESTED: ☐ STANDARD WATER/SEWER ☐ CONSTRUCTION – WATER ONLY SERVICE START DATE REQUESTED: Applications submitted and approved after 3 pm will be connected the next business day. APPLICANT’S INFORMATION Legal Name: Mailing Address if different than service address: Authorized contact, if account is under a business Previous Service in Woodburn: ☐ Y ☐ N If yes, what address: Phone Number: E‐mail: ☐ CO‐APPLICANT’S INFORMATION ☐ AUTHORIZED TO RECEIVE ACCOUNT INFORMATION Legal Name: Previously Lived in Woodburn: ☐ Y ☐N If yes, what address: Phone Number: E‐mail: If applicant is not the owner, please complete the following owner’s information: PROPERTY OWNER’S INFORMATION Name: Mailing Address: Phone Number: E‐mail: PROPERTY MANAGEMENT COMPANY INFORMATION (if applicable) Name: Mailing Address: Phone Number: E‐mail: I hereby agree to pay all bills for such service when due, and abide by all Ordinances regulating the use of City water and sewer service and any other rules and regulations which may be adopted by the City Council concerning said services. A deposit is required of owner and renters. If service is disconnected for non‐payment of the bill, there will be an added charge before reconnection can be made. All delinquent charges must be paid prior to any new applicant receiving water service. Copies of delinquency notices and shut‐off notices sent to renter are provided to property owner. Customer and/or property owner are required to maintain valid contact information and notify the City to schedule termination of service. Applicant’s Signature Date Co‐Applicant’s Signature Date