Form W 120A – Fill Out and Use This PDF

SERVICE NO: ________________

Municipal Authority of Westmoreland County

DATE: ______________________

I,, request that water service be Initiated at the following location:

Street/Lot/Plan__________________________________________________________ City_______________________________ ZIP _____________

Tax Map Number _______________________________________________________ County ____________________________________________

SERVICE MAY BE EXTENDED TEMPORARILY UNTIL VERIFICATION WITH THE OWNER/LANDLORD IS RECEIVED.

I am the OWNER / TENANT (circle one) of the property listed above. I agree to use the water according to the rules and regulations of the Authority, copies of which are available for public inspection at the Authority Office, and to pay for water service at the above location in accordance with the rules and rates approved by the Municipal Authority of Westmoreland County within fifteen (15) days from the date that I receive the bill.

I further agree that I will complete the information called for within this application. I understand that I may be required to post a security deposit. In the event that I am required to post a security deposit, the amount will be determined by the Municipal Authority to secure the utility from loss. The amount of any security deposit I may be required to post will be refunded in accordance with the rules and regulations of the Municipal Authority of Westmoreland County.

If No, previous service address:________________________________________________________ City____________________________________

Applicant Information:

Main phone number: ( _______ ) _______ - ________________Cell phone number: ( _______ ) _______ - ____________________

Employer: _______________________________________________________ Work phone number: : ( _______ ) _______ - __________________

Social Security Number: ________ - _______ - ________		Authorized Contact Person __________________________________________
Drivers License # ______________________________ State ____		E-mail Address ____________________________________________________
Spouse Information
Name:	______________________________________________________ Employer:		__________________________________________________
Work phone number: (______ ) _______ - __________________
In case of Emergency, contact:
Name:	______________________________________________________		Phone Number: ( ______ ) _______ - __________________

Address: _________________________________________________ City:____________________________ST: _______ Zip:__________________

Complete billing address if different from service address:

Street:_______________________________________________________ City: ____________________________ ST:_______ Zip: _____________

If TENANT, complete landlord information requested below:

Name: _____________________________________________________ Street: _______________________________________________________

City:____________________________________ State: ___________ Zip: _____________ Phone Number: ( _______ ) ________ - ___________

I represent that the above location is presently capable of accepting water service. I understand that this application is accepted subject to the availability of water at this location.

Applicant’s Signature: X____________________________________________________________ Date: ____________________________

Deposit Amount-Water $ ___________ Certificate # _______________ / Deposit Amount-Sewer $ ____________ Certificate # ________________

Comments/Additional Information: __________________________________________________________________________________________