Application for a New Account
                                               Corbett Water District
                                     36120 E. Historic Columbia River Hwy.
                                          PO Box 6  Corbett, OR 97019
                                                   (503) 695-2284

Date service to start: _________________Account #: _______________________
Applicant Name: _____________________________________________________________
Street Address of location: _____________________________________________________
Mailing address_______________________________________________________________
City: ___________________State: _________Zip: __________________________
Home Phone #:__________________ Alternate Phone #: _____________________________
Work Phone: ________________________   Email: _________________________________
Drivers License #:_______________________
Employer: __________________________________________________________________
Landlord Name (if rental): ______________________________________________________
Landlord Address_____________________________________________________________
Landlord Phone #: ____________________________________________________________

The landlord needs to be aware that if the renter’s water bill is not paid the landlord is responsible. The water service will not be restored until the amount of the water bill is paid in full.

Landlord signature: ______________________________________Date:_________________

Emergency Contact: __________________________________________________________
Phone #:_______________________Relationship: ______________________________

I hereby request that Corbett Water District furnish water to the above premises of which I am owner/tenant.  I agree to pay the regular rates and charges for water service at these premises and to abide by all rules and regulations proclaimed by the Board of Commissioners of the Corbett Water District as of now or hereafter in effect. 

Signature: _______________________________________ Date: ______________________

To open a new account with Corbett Water District you are required to provide a            $120.00 deposit.  This deposit is held until the time the customer leaves residence and the account is closed.  At which time the deposit will either be applied to the final bill or if the balance has already been paid it will be refunded via check only.  Please remit $120.00 deposit with your application.