FOR OFFICE USE ONLY: Cycle #____________
Bill from date: _______________
Processed by: _______________________________
Billed deposit amount: $___________
City of St Louis Water Division
APPLICATION FOR WATER SERVICE
PLEASE PRINT
Date: __________________
BILLING NAME
SERVICE ADDRESS ZIPCODE
MAILING ADDRESS (If different from Service Address)
CITY STATE ZIPCODE
TELEPHONE NUMBER
( )
Last 4 digits of SS# OR Complete FED ID# OR Complete Driver’s License Number
Do you want duplicate bills sent to an address other than the service or mailing address? YES NO
If yes, please provide the following information:
NAME ADDRESS
CITY STATE ZIPCODE
Who will live at this address? TENANT OWNER
IF TENANT IS APPLYING FOR WATER SERVICE, THE PROPERTY OWNER MUST
AGREE TO TERMS AND SIGN THE BACK OF THIS APPLICATION
Type of Property: Residential: Single Family Duplex Condominium Other _________
Apartment Bldg: Number of Units _____
Commercial: Tax Exempt? YES NO If yes, please submit Tax Exemption Letter
If extra work is needed to restore or initiate service that is not covered by the turn-on fee or the Service Line Insurance Program
(if applicable) it will be the owner’s responsibility. In those cases, if extra work is necessary, I/we agree to pay the Water Division
for the extra services or contact a private plumber to make repairs to turn on water service.
Applicant Signature: _________________________________________ Date: _____________
Account Number: _______________________________
