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Application for purchasing Bulk Water, Agreement Form

4. Application for Purchasing Bulk Water Agreement Form

6. Company Name

7. Applicant's Name

9. Mailing Address for Billing

11. City

12. State

13. Zip Code

15. Contact telephone Number

16. Email Address

20. Deposit
    Security deposit in the amount of $250.00 is required. Deposit will be waived if customer has had previously or current service with Roosevelt City. The deposit will be refunded after one year if the account is kept current or the account is terminated. The customer will be billed for each month at the rate of $10.00/1,000 gallons of water. Payment is due by the 25th of each month. Service can be terminated at any time by notifying Roosevelt City. Otherwise the company will be billed if there is usage until notification is given.

    Security deposit in the amount of $250.00 is required. Deposit will be waived if customer has had previously or current service with Roosevelt City. The deposit will be refunded after one year if the account is kept current or the account is terminated. The customer will be billed for each month at the rate of $10.00/1,000 gallons of water. Payment is due by the 25th of each month. Service can be terminated at any time by notifying Roosevelt City. Otherwise the company will be billed if there is usage until notification is given.

22. Signature of Applicant

23. Date
    Date

    Date

25. Send completed form with check to:
    Roosevelt City 255 S State Street 36-8 Roosevelt, UT 84066

    Roosevelt City 255 S State Street 36-8 Roosevelt, UT 84066

27. Location & Hours
    The facility is located at 2079 West 1600 South in the Airport Subdivision. Westside Storage Units, Western Petroleum Bulk, and Duchesne County Mosquito Abatement are some of businesses nearby. It is important that your customer code # is not visible to just anyone. If you are experiencing problems with the Bulk Water System, please contact Roosevelt City Offices at 435-722-5001 Weekdays Mon-Fri 8:00 a.m. - 5:00 p.m. After hours, Weekends and Holidays: Central Dispatch, 435-722-4558. The Dispatch Center will notify one of the Public Works Department staff member on call for the week.

    The facility is located at 2079 West 1600 South in the Airport Subdivision. Westside Storage Units, Western Petroleum Bulk, and Duchesne County Mosquito Abatement are some of businesses nearby. It is important that your customer code # is not visible to just anyone. If you are experiencing problems with the Bulk Water System, please contact Roosevelt City Offices at 435-722-5001 Weekdays Mon-Fri 8:00 a.m. - 5:00 p.m. After hours, Weekends and Holidays: Central Dispatch, 435-722-4558. The Dispatch Center will notify one of the Public Works Department staff member on call for the week.

31. Date Service will Start
    Date Service will Start

    Date Service will Start

33. Customer Number Assigned

34. Bulk Water Number Assigned

36. A copy of this form will be made for you with the number and information.

Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

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