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New Service Application

  1. 2018 Logo

  2. City of West Columbia Water Deposit and Application for Service

    Please complete the following information:

  3. Payment Options

    Please call to activate your service after submission of these forms, Monday through Friday 8am to 5pm at (979)345-3123. You make pay with debit/credit card by phone, in person, or place in city's night drop. (Located West of parking spaces.)

  4. Date of Birth

  5. Date of Birth

  6. Name of Employer

  7. Name of Employer

  8. Address Number & Street or P.O. Box

  9. Address Number & Street or P.O. Box

  10. City, ST & Zip Code

  11. City, ST & Zip

  12. XXX-XXX-XXXX

  13. XXX-XXX-XXXX

  14. Acknowledgement

    I acknowledge and agree that interest at the rate of 1.5% per month will be charged on all balances remaining unpaid after the account has been finaled in the event of default and referral to an attorney or collection agency. I agree to pay all costs of collection including reasonable attorney's fees. I understand that the above information is given for the purpose of obtaining service and certify that, to the best of my knowledge, the above information is complete and accurate as of the data of this application.

  15. Digital or typed signature

  16. Leave This Blank:

  17. This field is not part of the form submission.