Start, Stop or Transfer Service

Previous Service Address Information (optional)

Last service address (optional)

Previous account number (optional)

Requested Turn-Off Date (mm/dd/yyyy) (optional)
(Must be within 14 days of turn-on date)

New Service Address Information (required)

Service Address

Service Address Line 2 (Apt, Unit, etc.)

Service City

Service Zip Code

Requested Turn-On Date (mm/dd/yyyy)

Primary Applicant Information (required)

First Name

Middle or Maiden Name

Last Name

Birth Date (mm/dd/yyyy)

Driver's License #

Driver's License State

Primary Contact Phone

Primary Contact Email

Billing/Forwarding Address, If Different from Service Address (not required)

Billing Address

Billing Address Line 2 (Apt, Unit, etc.)

Billing City

Billing State

Billing Zip

Co-Applicant Information (not required)

First Name

Middle or Maiden Name

Last Name

Birth Date (mm/dd/yyyy)

Driver's License #

Driver's License State

Additional Persons

List any additional persons authorized on the account (not required). Will be able given balance information and allowed to make payments.

Landlord Contact Information (required if property not owned)

Landlord Name

Landlord Primary Contact Phone and/or Email

Comments (not required)

Acceptance of Conditions

I hereby request provision of water and/or sewer service by Brunswick-Glynn Joint Water and Sewer Commission for the premises described herein for which I agree to pay monthly at the schedule rate then in effect when due. I will give notice to the JWSC of my vacating or selling said premises. I will comply with the rules and regulations of the JWSC making them a part of this agreement. In the event of default of payment, the ordinances of the JWSC will apply and any fees assessed for such default will be my responsibility. I agree to claim no damage on account of the stoppage of the flow of water or sewer resulting from accident or the making of alterations, repair or improvement by the JWSC. I agree to keep all plumbing on the premises in repair and promptly stop all leaks. If I fail to comply with this agreement, or any part thereof, the JWSC may turn off the water and/or discontinue sewer services to the premises without notice to me. The JWSC reserves the right to contact the applicant herein at any of the locations described herein.

I consent to the conditions.

To reduce the risk of identity theft, you must include the following item:
Attach Government-Issued Photo ID (pdf, jpg or png - 10 mb max)

Attach proof of another utility bill established in your name - must show new service address listed above (pdf, jpg or png - 10 mb max)

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