APPLICATION FOR SERVICE
The following information is required for the purpose of opening an account. A deposit of $120.00 is required
prior to the initiation of service. A base charge for North Brevard water and sewer will be billed every month
regardless of usage and a $15.00 set up fee will be charged to your first bill. Make all checks payable to
Brevard Water and Sewer. A photocopy of the applicant’s and co-applicant’s driver’s license is required to be
submitted with this application.
Applicant’s Name: __________________________________________________________________________
Co-App
licant’s Name: _______________________________________________________________________
Servic
e Address: ____________________________________________________________________________
Mai
ling Address, (if different): ________________________________________________________________
Pri
mary Phone Number: _____________________ Secondary Phone Number: _________________________
Email Address: _______________________________________ Date of Initiation of Service: ______________
Alt
ernate Contact: ________________________ Alternate Email Address: ____________________________
App
licant Information: Own* Rent**
* If th
e applicant is the owner, submit a copy of the HUD-1 settlement statement from the closing, or the
owner information needs to be updated on the Brevard County Property Appraiser’s website at the time of
application.
** If this is a rental, you will need to provide a copy of the lease and the following information:
Pro
perty Owner’s Name: _____________________________________________________________________
Pro
perty Owner’s Address: ___________________________________________________________________
Property Owner’s Phone Number: _____________________________
By signing below, I acknowledge and agree to the following: I hereby certify that all the information
provided in this application is true and correct to the best of my knowledge. I understand that I am
responsible for the prompt payment of all charges at the above service address. I agree to abide by any and
all regulations, policies and procedures for the provision of water and wastewater services as established
and may be modified by the Brevard County Board of County Commissioners.
______
_____________________________________ __________________________________________
Applicant’s Signature and Date Co-Applicant’s Signature and Date
UTILITY SERVICES DEPARTMENT
North Brevard Water & Sewer
2262 High Dr.
Mims, FL 32754
Phone: 321-264-5130
Email: Mims.Billing@brevardfl.gov
