NEWTON COUNTY WATER & SEWERAGE AUTHORITY
APPLICATION FOR SERVICE
HOMEOWNER: $55.00 RENTER: $80.00
CUSTOMER NAME: _________________________ CO-APP NAME: _______________________________
SERVICE ADDRESS: ____________________ LOT #: _______ BUILDER NAME: ____________________
MAILING ADDRESS: ___________________________ CITY, STATE, ZIP: __________________________
START SERVICE ON: _________________
TRANSFER: YES/NO PREVIOUS ADDRESS: ______________________ DISCONNECT DATE: ______
HOME #: ____________________ CO-APP HOME #: _________________________
WORK #: ____________________ CO-APP WORK #: _________________________
CELL #: CO-APP CELL #:
SSN: ________________________ CO-APP SSN: _____________________________
DRIVERS LIC #: ______________ CO-AP D.L. #: _____________________________
DATE OF BIRTH: _____________ CO-APP D.O.B.: ___________________________
EMAIL: CO-APP EMAIL:
EMPLOYER NAME & ADDRESS CO-APP EMPLOYER NAME & ADDRESS
_____________________________ __________________________________________
_____________________________ __________________________________________
_____________________________ __________________________________________
REFERENCE: (preferable a relative, if living in GA) NAME: _______________________________________
RELATIONSHIP: ___________________________ ADDRESS: ____________________________________
PHONE #: _________________________ CITY, STATE, ZIP: ______________________________________
To induce Newton County Water & Sewerage Authority to accept this application, the Applicant unconditionally agrees to comply with all the Authority rules and regulations, and to promptly pay for all water used. This includes
all late fees and other charges as they may apply. The Applicant further acknowledges sole responsibility for any accrued cost by the Authority to cause replacement or repair to Applicant’s water service due to damage and/or tampering.
SIGNATURE: ___________________________________ DATE: _____________________________
***Return the completed application, a copy of your driver’s license, a copy of your settlement statement or lease agreement, along with a check or money order for your deposit (Homeowner $55.00, Renter $80.00) to NCWSA, P.O. Box 1137, Covington, GA 30015 or you can come to our office located at 11325 Brown Bridge Road, Covington, GA 30016 to apply for service. You can also fax the requested information to 770-385-3966 and then a Customer Service Representative will contact you for your credit card information. We will need to complete your application one day before the service should be put into your name because we are next day service.***