Water/Sewer Online Application

Name*
First Middle Last
Date Service Requested*
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Service Address (Premise)*
State*
Mailing Address (If different)
Home Phone Number
Cell phone #*
City, State, Zip*
Work Phone Number & Extension Number
Employer*
Employer’s Address*
Spouse’s name (Optional)
Date of Birth (Optional)
MM slash DD slash YYYY
Spouse’s Employer (Optional)
Spouse’s Employer’s Phone # (Optional)
Applicant’s Email*
Spouse’s Email (Optional)
Consent*
I understand that I am responsible for all water usage at the property and I will pay all bills owed by me by the due date. I will abide by and comply with all ordinances, specifications, and regulations of the Wilmore Utilities System. I will continue to be responsible for same until my account is closed following the normal procedures of the Wilmore Utilities System. By my signature below, I acknowledge that I understand and agree with all of the above.
Signature*
Date*
MM slash DD slash YYYY
I hereby acknowledge that I am responsible for any additional fees that might incur during collection of the final bill.*
(Initial)
*The water system in High Bridge service area and the South East County service area has separate and higher water rate schedules, and the water lines in those areas are NOT designed or intended for fire protection.
Remit to: Wilmore Utilities System Deposit amount: $150.00

210 S. Lexington Ave., Refundable after 5 years

Wilmore, KY 40390 Or applied to final bill
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