W/S Hookup Application

CITY OF DEER CREEK

106 Maine Avenue E       P.O. Box 272

Deer Creek, Minnesota   56527-0272

APPLICATION FOR WATER/SEWER SERVICES

I/WE AGREE TO SUPPLY THE CITY CLERK’S OFFICE WITH MY FORWARDING ADDRESS AND THE FINAL PAYMENT WITH 10 DAYS OF THE DATE OF THE FINAL BILL.

I/WE UNDERSTAND THAT PAYMENT FOR WATER/SEWER SERVICE IS REQUIRED IN FULL BY THE 15TH OF EACH MONTH.  A LATE FEE OF $15.00 SHALL BE IMPOSED ON ALL UNPAID SEWER AND WATER BILLINGS IF NOT PAID BY THE 15TH OF THE MONTH.  I/WE ALSO UNDERSTAND THAT MY SERVICE MAY BE DISCONNECTED FOR NON-PAYMENT AFTER THE 25TH OF EACH MONTH.  I/WE ALSO AGREE TO PAY A $30.00 DISCONNECTION FEE AND A $30.00 RECONNECTION FEE, AS WELL AS TWO MONTHS OF SERVICE IN ADVANCE IF YOUR WATER/SEWER IS DISCONNECTED.

Today’s Date ___________________

                Account ______________________

First and Last Name ______________________________________________________________

No. of Persons in Household ________                                  Heat Source __________________ Source____________________

Address for Person/Sewer                                                           Mailing Address

____________________________ ____________________________       ____________________________           ____________________________


Home/Cell Telephone _________________________

Work Telephone _____________________________

Date Service Requested _______________________

Email Address _______________________________

APPLICANT DATA RECORD

Please provide the following information so that the City of Deer Creek will be in compliance with Title VI of the Civil Rights Act of 1964.

In order to meet the requirements of the Federal Register Vol. 62 No.210, Revision to the Standards for the Classification of Federal Data on Race Ethnicity, all application forms for the City Utility connections must include below the signature line and date block the following disclosure statements.

Please check the appropriate information below:

The City of Deer Creek is an Equal Opportunity Provider and Employer

RACE & ETHNICITY

Please provide the following information so that the City of Deer Creek will be in compliance with Title VI of the Civil Rights of 1964.

The information regarding race, color, or national origin designation is requested in order to assure the Federal Government that the City of Deer Creek complies with Federal Laws prohibiting discrimination on the basis of race, color, or nation origin.  You are not required to furnish this information, but are encouraged to do so.  This information will not be used in evaluating your request for services or to discriminate against you in any way.  However, if you choose not to furnish this information, we are required to note your race/color/national origin on the basis of visual observation or surname.

Please check the appropriate information below:

RACIAL CATEGORIES (check one)                                               ETHNIC CATEGORIES (check one)

____ American Indian or Alaskan Native                                ____ Hispanic or Latino

____ Asian                                                                                          ____ Not Hispanic or Latino

____ Black or African American

____ Native Hawaiian or Other Pacific Islander

____ White

____ Some Other Race

____ Two or More Races

DATE: ___________________

Who filled out this form? (check one)

____ Participant

____ Employee Observed 3.2