Applicant Name (legal name): *

Service Address: *

City, State:    Zip Code:

Billing Address:

City, State:    Zip Code:

Drivers License No:    State:    Social Security No: ^{* initial section below}

Phone No. (Primary): * Phone No. (Secondary):

Email Address:    Passcode: ^{(if you desire exclusive access to account)}

Spouse's Name:    Spouse's Phone:

If Applicant Name above is a Business Name:
Contact Name: Fed Tax ID #:

Own    Rent   Note that lease or proof of rental must be provided 

If Renter, provide Landlord Name:    Landlord Phone:

Date requested to start new service *

Type of customer:
     Current BRWA Customer    Prior BRWA Customer    New Customer   

If Current or Prior, enter Service Address: 
    

If disconnect requested on current address, enter disconnect date requested:

Statement of Agreement

By entering your name below, this agreement is a contract under which BRWA agress to furnish water and the customer agrees to pay for such service in accordance with applicable rates and fees, and abide by the terms of service. If applicable, customer will be billed by BRWA for sewer and/or sanitation services furnished to customer by the Town of Rutherfordton, Town of Spindale, or Cliffside Sanitary District, in accordance with applicable rates, fees, and terms of service established by the respective entities.

There is no outstanding delinquent debt for utility services, fees or penalties due to BRWA, under an agreement, written or implied, made by me or by another person who is now or has been a member of my household or who resides at the above address, and I am responsible for the payment of all utility service charges at this address and for conformance with the terms of this agreement and all policies of BRWA.

I agree that BRWA has the right to enter upon my property for the purpose of maintaining and operating its facilities, and may exercise the right to discontinue services and remove its facilities in case of violation of any of the terms of this agreement, or if any of the information I have provided is found to be incorrect.

Initials: * Disclosure of SSN is voluntary and will be used for collection of delinquent balances to the North Carolina set-off debt collection program and/or a third party collection agency.

Enter Your Legal Name as digital signature and click Submit:
*