Customer Name: 
Service Address: 
Billing Address:   
City or Town:         
State:                                                             Zip Code:  
Phone:                      Alt Phone:  
I am applying for water service exclusively for the service address above and agree to be responsible for payment
of the water bill as of  
The use of service is:                Residential                Commercial              Industrial

 have   have not had service in my name from this utility before.

A member of my household   does  does not have a medical condition, life support equipment, or other circumstances
which require emergency restoration if water service is interrupted.

I agree to comply with all applicable Rules and Regulations of the Maine Public Utilities Commission and the
Terms and Conditions
of the South Berwick Water District.

Do you own the property?    Yes        No
If not, please give the property owner's name and address:

Today's Date:             Applicant's Signature: