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Residential Application

Please call the Main Office at (910) 371-9949 to pay fees associated with this application.

Owner/Tenant:

Owner/Tenant Birth Date:

Driver's License #:

Driver's License State:

Name Of Spouse:

Spouse Birth Date:

Driver's License #:

Drive's License State:

Mailing Address:

City:

State:

Zip:

Service Address:

Lot #:

Sub-Division:

Town:

Telephone:

Home No:

Office No:

Cell No:

Email:

I agree to pay the Brunswick Regional Water & Sewer monthly charges as computed by the monthly rate schedule in effect at the time of usage and initial hook up fees as described below:

	Water	Irrigation	Sewer
1. Sec Deposit
2. Admin Fee		(NON REFUNDABLE)

Total Charges ($)

Owner/Tenant Electronic Signature*:

Owner/Tenant Signature Date:

Co-Tenant Electronic Signature:

Co-Tenant Signature Date:

Responsible Party Electronic Signature*:
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Please call the Main Office at (910) 371-9949 to pay fees associated with this application.

* required signatures