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3. First Name*
4. Middle Initial
5. Last Name*
6. Suffix
8. Phone Number*
9. Type of Phone Number:*
   -- Select One --CellHomeWork
10. Email Address*
12. Service Location Address*
13. Suite or Apt#
15. Water Account Number*
20. Description
22. Payment Confirmation Number
23. Amount of Payment
24. Method of Payment
    -- Select One --Online PaymentPhone PaymentMail-In PaymentAfter-Hours Dropbox Payment
26. If paid via check, please provide the front and back image of the check.
28. Attach Additional Documents
29. Attach Additional Documents
30. Attach Additional Documents
32. Notice regarding electronic signature

    Pursuant to the North Carolina Uniform Electronic Transactions Act, digital application documents are legally binding in the same manner as are hard copy documents executed by hand signature. The applicant hereby consents to the use of electronic or digitized signatures or scanned copies of original signatures, and the applicant intends to be bound by the application and any related documents.

    By submitting an application with an electronic or digitized signature or a scanned copy of the original application, you acknowledge, agree, and authorize your electronic or digitized signature or your scanned original signature to be valid and binding upon you in the same manner as are hard copy documents executed by hand signature.

34. "Sign" your application by typing your name below:*
35. Date:*
    Date:
Leave This Blank:


37. Submit

* indicates a required field