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2. Rockingham County
   Water & Sewer - Application For Service
4. Deposit Rates

   Owner Deposit:	Renter Deposit:
   $50 Water Only	$75 Water Only
   $50 Sewer Only	$75 Sewer Only
   $100 Both	$150 Both

   
   

6. Last Name*
7. First Name*
8. Middle Name
10. Last Name
11. First Name
12. Middle Name
14. Water Service

    1. Water
15. Sewer Service

    1. Sewer
17. Date Service To Start: **Must be tomorrow's date or later (no weekends)*
    Date Service To Start: **Must be tomorrow's date or later (no weekends)

    ** Note:  For applications received after 4:30pm , the start date must be at least 2 days later.

19. Street Address*
21. City*
22. State*
23. Zip*
25. Applicant 1 - Phone Number*
26. Applicant 1 - Email Address*
28. Applicant 2 - Phone Number
29. Applicant 2 - Email Address
31. Mailing Address If Different From Service Address
33. City
34. State
35. Zip

37. I (We) are the:

39. Owner

    1. Owner
40. Tenant

    1. Tenant
41. If Tenant, owner is:

43. and owner has indicated approval of the County's provision of service. I (We) understand that connections made are to be in conformance with existing policies and ordinances of Rockingham County and agree to pay for service(s) at the rates and fees established by and as may be revised by the Rockingham County Board of Supervisors. I (We) further understand that service(s) may be discontinued in the event bills are not paid when due. 

    *DEPOSITS ARE RETURNED AFTER 12 CONSECUTIVE MONTHS OF PAYMENTS RECEIVED ON TIME & NO INTEREST CHARGES*

45. Acknowledgement*

    1. I acknowledge the information given above is true and correct to the best of my knowledge.
46. Date*
    Date
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field