Application for Consumer Residential

Complete the online form below or print and complete the .pdf form here and mail to PO Box address listed below.

LIMESTONE COUNTY WATER & SEWER AUTHORITY
P O BOX 110
520 S JEFFERSON ST
ATHENS AL 35612
256-233-6444

* required fields
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Date of Application:
Requested Date of Service:

Name of Applicant
Last Name*:
First Name*:

Spouse/Co-applicant
Last Name:
First Name:

List name of all other adults living in the home:

Address of New Service
Address*:
City*:
State*:
Zip*:

Mailing Address (if different from above)
Address:
City:
State:
Zip:

Email*:
Do You Prefer ebilling? YesNo

Contact Numbers:
Home Phone Number:
Cell/Alt Number:

Driver's License Number:
Co-app. License Number:

Applicant's Employer:
Work Phone:
Employer address:

Do you own or Rent the Property? OwnRent
If Renting, List Landlord/Owner's Name:
Mailing Address:
Landlord Phone:

Attach Rental Agreements (if applicable):

Have you had service with Limestone County Water before? YesNo
If yes, list address:
If No, list prior utility provider:

If transferring service with Limestone County Water, list the service address of disconnect:

Date of Disconnect:

THIS APPLICATION IS A PERMANENT RECORD. IT IS IMPORTANT THAT YOU MAKE SURE ALL ARE CORRECT. SHOULD
THE INFORMATION YOU PROVIDE BE FALSE, YOUR SERVICE COULD BE SUBJECT TO TERMINATION WITHOUT FURTHER
NOTICE. INFORMATION CONTAINED IN THIS APPLICATION IS FOR THE SOLE USE OF LCWSA; THE ACCURACY OF WHICH
MAY BE VERIFIED BY LCWSA.

LCWSA DOES NOT SELL OR SHARE ANY OF THE INFORMATION ON THIS APPLICATION UNLESS SPECIFIED BELOW.
LCWSA RESERVES THE RIGHT TO REQUIRE AND/OR REQUEST ADDITIONAL INFORMATION OF AN APPLICANT SUCH AS,
BUT NOT LIMITED TO, COPY OF A DEED OR RENTAL/LEASE AGREEMENT.

AGREEMENT
The undersigned Owner (hereinafter called the "Customer") hereby makes application for and agrees to take from the
Limestone County Water & Sewer Authority (LCWSA) the service or services covered by this application at the address
given above until Customer notifies LCWSA n writing that Customer wishes to have the service or services turned off, and
agrees to be responsible for the payment of all bills for utility services at the above address. Customer understands
prompt payment for service is required in order to avoid termination of services at the above location. Customer
acknowledges that each bill received is a stated account and that the amount due on a bill is deemed correct unless
Customer contests the amount due within thirty days of receipt. As permitted by applicable law, LCWSA reserves the right
to transfer a Customer's prior delinquent account balance to this new account upon verification of the identity of the
Customer.

Customer agrees to permit the authorized agents of LCWSA free access to the premises of the Customer for the purpose of
inspection prior to the connection(s) of service of a type or character to determine that all service types comply with all
applicable local, State, and Federal Building Codes.

Customer agrees to permit the authorized agents of LCWSA free access to premises for the purpose of connecting,
disconnecting, inspecting, testing, reading meters, repairing or removing any property of LCWSA, and agrees not to permit
anyone, including the Customer, to deface, damage, or otherwise tamper with the property of LCWSA.

LCWSA makes reasonable provisions to insure satisfactory and continuous service, but it does not guarantee continuous
service, and will not be liable for loss or damage caused by accidents or conditions which it could not have foreseen or
over which it has no control.

Customer authorizes LCWSA to request and retain a credit report, payment history, and/or service verification on any
person or entity making application for utility service from LCWSA at any time and in its discretion. This information may
be used for collection purposes. LCWSA shall have the authority to report payment history to other utility service
providers. LCWSA shall have the authority to report to credit service(s) relevant payment information on all persons or
entities listed above when payment of the utility account remains delinquent for more than sixty (60) days. LCWSA shall
have the authority to refer the utility account which remains delinquent for more than sixty (60) days to a third party for
collection purposes. LCWSA shall have the authority to file suit to collect amounts owed LCWSA for utility services and
charges that remain delinquent for more than sixty (60) days. In the event LCWSA files suit to collect amounts owed, the
Customer shall be responsible for all attorneys' fees and costs of collection. All applicants, and responsible adults whose
signatures are below are subject to the provisions of this document.

I/we (the customer(s)) understand that the connection/service fee paid today is not a deposit and is nonrefundable and will
not be waived based on payment history or credit score.

I/we certify that the information provided for this application are true and correct, and that I/we have read this application
in its entirety and understand its contents.

I accept:

Today's Date: