Application for Service

Name(s)*

Mailing Address*

Mailing Address

Service Location*

Property Type*

Residential

Non-residential

Mix of residential and non-residential

Residential Information*

single family

multi-unit

home occupation on site

Number of Units*

% of building used for non-residential purposes*

[information required by Maine Revenue Services (207) 624-9693]

Residential building has fire sprinkler connection on domestic line. # of sprinkler heads:*

Owner Information*

Owner of property

Tenant

Provide landlord information below
(Note that application/account information may be provided to the landlord by law.)

Landlord*

Landlord address*

Employer/source of income*

Daytime phone(s)*

Email*

Previous service with Bangor Water*

Yes

Previous address

Do you have unpaid bills at this utility or for any other kind of utility service?*

Yes

Have you declared bankruptcy within the past six years?*

Yes

Does anyone at this location have a medical condition that requires life support equipment or emergency restoration of water if service is interrupted?*

Yes

Doctor certification is required

I hereby contract for water service (domestic and/or fire protection), and agree to abide by terms of service (including termination of water/fire protection for non-payment) and related requirements until I give proper notice to terminate service. I understand that: my account information may be used for debt collection by Bangor Water; the information I provide is subject to verification; and provision of incomplete or false information is grounds for termination of service and possible law enforcement.

Signature*

Person 1

Signature

Person 2

Name*

Person 1

Name

Person 2

Signature required for each person on account

Date*

Phone

This field is for validation purposes and should be left unchanged.

Article Title: Application for Service

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Article Title: Application for Service

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