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2. 
4. City of West Columbia Water Deposit and Application for Service
   Please complete the following information:
6. Last Name*
7. First Name*
9. Last Name - Spouse
10. First Name - Spouse
12. Select Service Type
    -- Select One --Renter $200 + $12.50 Service FeeOwner $75 + $12.50 Service FeeBusiness - Please Call for Deposit Rates - (979)345-3123

    Select One

14. Property Owner's Full Name
15. Property Owner's Cell Phone Number
17. 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.)
19. Service Street Address *
21. Mailing Address (if different)
23. City
24. State
25. Zip
27. Self *
    Date of Birth
28. Spouse
    Date of Birth
30. Employer
    Name of Employer
31. Spouse's Employer

    Name of Employer

33. Employer's Address
    Address Number & Street or P.O. Box
34. Spouse's Employer's Address

    Address Number & Street or P.O. Box

36. Employer's Address
    City, ST & Zip Code
37. Spouse's Employer's Address

    City, ST & Zip

39. Cell Phone Number*

    XXX-XXX-XXXX

40. Spouse's Cell Phone Number

    XXX-XXX-XXXX

42. Texas Driver's License Number*
43. Spouse's Texas Driver's License Number
45. 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.
47. Signature*
    Digital or typed signature
49. Voluntary Ambulance Charge
    -- Select One --$1$2$3I do not wish to participate at this time

    Your account is automatically charged $3 unless you indicate otherwise.
50. Voluntary Fire Department Charge
    -- Select One --$1$2I do not want to participate at this time

    Your account is automatically charged $2 unless you indicate otherwise.
52. Date of Application*
    Date of Application
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field