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Application for Water Service

Customer Information

First Name

Last Name

Phone

( ) -

Mobile

( ) - (Optional)

E-mail

Confirm E-mail

Service Information

Service Start Date

Address 1

Address 2

(Optional)

City

State

Zip

-

Mailing Information

Same as Service Address

Address 1

Address 2

(Optional)

City

State

Zip

-

Customer Acknowledgement

I hereby agree to abide by the Big Bend Water District Service Rules and further do agree to pay all water usage charges that may accrue to my account prior to final service disconnection.