Fillable SERVICE ORDER TURN ON (County of Henry)

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SERVICE ORDER TURN ON (County of Henry)

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U.S.A. forms for County of Henry

BROWSE COUNTY OF HENRY (VA) FORMS

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HENRY COUNTY PUBLIC SERVICE AUTHORITY
SERVICE ORDER TURN ON
SCHEDULE A DISCOUNT ( ) DISABLED DEPOSIT PAID:________________________
NAME #1_______________________________________ ACCOUNT #______________________________
NAME #2_______________________________________ CUSTOMER #____________________________
SERVICE ADDRESS:_______________________________________________________________________
MAILING ADDRESS:_______________________________________________________________________
MAILING ADDRESS:_______________________________________________________________________
HOME PHONE:_________________________________ WORK PHONE:___________________________
DATE OF BIRT H:________________________________ EMPLOYER:______________________________
SS #1:_________________________________________ SS #2:____________________________________
IF TENANT, PROVIDE FOLLOWING IN ADDITION TO COPY OF LEASE:
LEASE DATE:___________________________________
LANDLORD NAME:______________________________
LANDLORD ADDRESS:____________________________________________________________________
LANDLORD ADDRESS:____________________________________________________________________
LANDLORD TELEPHONE NUMBER:_________________________________________________________
I/We confirm that I am the ( ) legal owner, ( ) agent of owner, or ( ) tenant of the property
where service is requested.
I/We agree to use and pay for the service in accordance with the Henry County Public Service
Authority Rules and regulations for water and sewer service which are or may come in force during
the life of this contract.
In accordance with the Code of Virginia Sec. 15.2-5139 as amended, a lien may be placed on this
property for nonpayment of utility charges and interest on this account.
SIGNATURE:_______________________________________________DATE:_________________________
SCHEDULED TURN ON DATE:___________________________________
METER READING:__________________________
NEW READING:___________________________ BY:_____________________
NOTE: BE SURE ALL WATER IS TURNED OFF AT THE LOCATION OR WE WILL NOT BE ABLE TO
CONNECT YOUR SERVICE AS SCHEDULED.
Account Type
Residential
Non-Residential
Institutional
This facility is operated in a nondiscriminatory basis with regards to race, color, national
origin, religion, sex, familiar status, age, or handicap. Complaints of discrimination may
be sent to the U.S. Secretary of Agriculture, Washington D.C. 20250
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SERVICE ORDER TURN ON (County of Henry)

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Completed 17 July 2020

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