Without further notice pending satisfaction of District requirements. The water service can only become permanent upon satisfaction of District requirements, including payment of outstanding bills, completion and signing of this form, and presentation of verifiable proof of ownership as specified to you verbally. (Policies, Procedures, Rules and Regulations 7:02.A2) Quartz Hill Water District is not responsible for nor does it guarantee the quality of water to be delivered to its customers. This Application for Water Service is to be completed and signed by the owner of the property. In the event that a properly signed form is not on file with the District, the water service will be subject to discontinuance without further notice. The owner may request that the bill be sent to another person, such as the tenant at the property address. The owner may also instruct the District to send the bill to himself at another mailing address or a property manager. The purpose of this form is to provide the District with the correct billing information and to notify the property owner that he/she is ultimately responsible for the water bill for the property to the extent permitted by law

Date Service Request

Name (required)

Service Address (required)

City (required)

Zip (required)

Home Phone

Cell Phone (required)

Email Address (required)

Preferred Billing Method (required)

Paper

Paperless

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Owner's Address (if different)

Address

City, State, Zip

C/O (tenant or property mgr info)*

Address

City, State, Zip

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*Owner understands that by sending bills to another party does not relieve them as the obligor

Work Phone

Name & Phone number of Emergency Contact (required)

Date Service Requested:

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Tampering with District equipment may result in meter removal and repair charges to be paid before service will be restored. It is agreed that Quartz Hill Water District shall not be responsible for damages to persons or property caused by failure or defects of pipes, high or low pressure, by escape or leakage due to conditions on said premises existing at or after beginning service and applicant will hold Quartz Hill Water District harmless therefrom. By signing this application, the applicant agrees to the terms and conditions of service set forth in the District Policies, Procedures, Rules and Regulations. Upon signing this application, customer also acknowledges receipt of the Welcome Bulletin.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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