CITY OF FORT CALHOUN
Water/Sewer Service Application   

                                                                                                                                   
Date: _____________________  email address: ____________________________________________

Name: ________________________________   Spouse's Name: ______________________________ 

SS#: __________________________________  Spouse's SS#: ________________________________

Address Moving to: ___________________________________________________________________

Mailing Address: _____________________________________________________________________

Home Phone: ___________________________ Work Phone: _________________________________ 

Employer: ___________________________________________________________________________

Spouse's Employer: ___________________________________________________________________ 

Previous Address: ____________________________________________________________________ 

Previous Utility: ______________________________________________________________________ 

If Renting - Landlord's Name: __________________________________________________________

Landlord's Phone Number: ____________________________________________________________ 

FOR NEW SERVICE LOCATIONS
Legal Description:  ____________________________________________________________________ 

Plumber: ____________________________________________________________________________

IF YOU WISH TO DESIGNATE A "THIRD PARTY" TO BE NOTIFIED IN CASE OF 
DISCONNECTION OF SERVICE, PLEASE INDICATE. IT WILL BE NECESSARY FOR YOU TO 
INFORM THIS PERSON THAT HE/SHE IS YOUR "THIRD PARTY". 

Name: ______________________________________________________________________________

Address: ____________________________________________________Phone: __________________

The undersigned Customer requests the Public Works Department of the City of Fort Calhoun, 
Nebraska, to furnish the following service/services: WATER _____ SEWER ______, and for such 
service, Customer agrees to pay the City of Fort Calhoun's rates as amended from time to time 
and filed with the City Council. Customer agrees that service will be furnished as required by 
City Ordinances and the Service Policies and Conditions of the Water and Sewer Departments 
as amended from time to time and filed with the City Council. 
 
Customer agrees to notify the City Clerk when service is no longer desired.

CUSTOMER HAS RECEIVED A COPY OF THE FORT CALHOUN WATER AND SEWER 
POLICIES & CONDITIONS.

SIGNATURE ____________________________________________________________________

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