City of Galena
211 W. 7
th
* Galena, Kansas 66739
Phone (620) 783-5265 * Fax (620) 783-5111
The Oldest Mining Town in Southeast Kansas
1877
DATE WATER IS TO BE TURNED ON: ____________________________________________
ADDRESS TO BE TURNED ON: _________________________________________________
ACCOUNT #: __________________________________
This information was taken by: ______________________________________________________ Date: ________________ Time: ______________
OWNER
Owner’s Name: __________________________________________________________________ Phone #: _________________________________
Owner’s Email Address: ____________________________________________________________________________________________________
Property Address:
Number/Street City State Zip
Owner’s Place of Employment: ______________________________________________________________________________________________
Owner’s Billing Address:
Number/Street City State Zip
RENTER
Renter’s Name: ________________________________________________________________ Phone #: ___________________________________
Renter’s Email Address: ____________________________________________________________________________________________________
Number of people that will be living at the address: _____________
Renter’s Billing Address:
Number/Street City State Zip
Deposit Date: ____________________________________ Amount: $75.00 Check _____________ Cash ________ Charge ____________
Driver’s License: _______________________________________ State Issued: _________________________ SS#: ___________________________
I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY BILLS THAT ARE ACCUMULATED AT THIS ADDRESS AS LONG AS THE ACCOUNT IS IN MY NAME.
I UNDERSTAND THAT I WILL BE BILLED FOR THIS ADDRESS UNTIL I CONTACT CITY HALL AND HAVE THE WATER TAKEN OUT OF MY NAME.
Signed: ___________________________________________________________________________________ Date: _________________________
NOTES: _________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
MUST BE FILLED OUT BY EMPLOYEE
CURRENT READING: ______________________________________ CITY EMPLOYEE: _______________________________________________
WORK COMPLETED BY: ___________________________________________________________________ TIME: _______________________
City of Galena, Kansas 211 W 7
th
Street, Galena, Ks 66739 Phone: 620-783-5265 Fax: 620-783-5111
