UTILITY APPLICATION CARD
Village of Whitehouse, Ohio
Date: Homeowner Renter
Name:
Property Address:
Mailing Address (if different from property address):
Phone Number: Email:
The undersigned, owner or renter of the premises listed above, hereby makes application for
water, sewer and refuse pick-up service from the Village of Whitehouse, I hereby agree to pay
and use such services in accordance with and subject to the by-laws and regulations of said
Village.
All applications for the use of water, sewer and refuse pick-up must be approved by the Village
of Whitehouse. A security deposit in the amount of one hundred dollars ($100.00) will be
required for all rental properties and some business accounts.
If the property is located outside the Village limits, all water and sewer service will have an
additional charge of 110% of the total bill for such services rendered.
Applicant Signature:
For Office Use Only
Deposit: Y N
Deposit Amt: Payment Type: CK Cash CCD
Clerk: Account #:
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signature
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