Step 1 of 4 25% Effective Date* Full Applicant Name* First Middle Last Co-Applicant Name, if applicable First Middle Last Applicant Email* Phone*Mailing Address* Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SS# or Fed Tax ID#*Drivers License#Applicant Date of Birth* Previous Property Owner* First Last Property Location*Town*Map & Lot*Type of Service*ResidentialCommercialGovernmentEffective Date of Service* ResidentialResidential Type*Single FamilyRentalApartmentCondoDuplexSeasonal?*YesNoPlease describe seasonal meter location explaining where customer wants service line to run:*Will there be a Pressure Tank/Booster Pump installed on public water supply?*YesNoWill there be:* Fire Protection Pool Underground Irrigation (Requires Separate Line) None of the Above CommercialNote: When calculating demand and flow, seasonal customers are to base calculations on one-hundred and eighty (180) day season.Business Name:*Peak Demand (gpm)*Peak Daily Flow (gpd)*Peak Pressure Need (psi)*Ave. Demand (gpm)*Ave. Daily Flow (gpd)*Ave. Pressure Need (psi)*Peak Flow Season*Peak MonthsSeasonal?*YesNowSprinkler System Required?*YesNow(for fire protection)Sprinkler Line Size*Water Use:*Check Applicable Restraurant Entertainment Heavy Manufacturing Primary Food Processing Inn, Hotel, or Motel Professional (non-medical) Harvested Sea Products Irrigation Retail (non-perishable) Professional (medical) Agriculture Nursing Home Retail (perishable) Light Manufacturing Aquaculture Day Care Please specify the percentage of property that is used for Business*This is for Maine State Bureau of Taxation. All water used for business purposes is taxable.Please specify the percentage of property that is used for Residential*This is for Maine State Bureau of Taxation. All water used for business purposes is taxable.Please Provide # of FixturesKitchen Sink*Dishwasher*Washer*Laundry Tub*Outside Spigot*Lavatory*Bathtub/Shower*Toilet with Flush Tank*Toilet with Flush Valve*Others: Please ListGovernmentPlease Select Government Type*LocalStateFederalQuasi-MunicipalWater Use:*Seasonal*YesNoFire Protection/Sprinkler Required*YesNoAdditional Information/Comments Credit InformationApplicant Place of Employment or Source of Income*Do you owe any outstanding bills for water?*YesNoDo you owe any outstanding utility bills of any kind?*YesNoHave you filed for bankruptcy within the past 6 years?*YesNoAnnual or Seasonal?*ANNUAL: Year round water service at the same premise. (Quarterly Billing)SEASONAL: Seasonal water use includes intermittent use, season after season, at the same premises. (Seasonal Billing)Percentage Used for Business*Please specify the percentage the property is used for Business purposes. This is for Maine State Bureau of Taxation. All water used for business purposes is taxable. If not completed, Commercial property will be taxed at 100% Must be broken down to nearest 10%.Percentage Used for Personal*Please specify the percentage the property is used for Business purposes. This is for Maine State Bureau of Taxation. All water used for business purposes is taxable. If not completed, Commercial property will be taxed at 100% Must be broken down to nearest 10%Credit References (Businesses you have had credit with. Example: Electric Company, Fuel Company, Landlord.)Credit Reference Name* First Last Contact Number*Credit Reference Name* First Last Contact Number*Credit Reference Name* First Last Contact Number* Civil Rights Information Collection for USDA Financed Organizations USDA financed facilities that use applications to determine eligibility for receipt of benefits or services or for informational purposes, will put the slogan "Equal Opportunity Program" on the bottom of their application forms and informational brochures. Recipients using application forms shall establish a section at the end of the form, below the signature and date block or a separate card/sheet to collect race/national origin information. In addition, the following disclosure notice shall be included "The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in the program. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/nationality origin of individual applicants on the basis of visual observation or surname.Race* White Black Hispanic American Indian or Alaskan Native Asian or Pacific Islander I prefer not to answer SexMaleFemaleI prefer not to answer Recipients using application forms will provide services and benefits in the order applications are received. A current waiting list will be maintained by the date and time an application is received, name of the applicant, race/national origin and a summary of the action taken Above records will also reflect the number of applicants approved or rejected for the benefit or service by race/national origin. The recipient shall make a report of this information available to Rural Development employees, USDA officials, and other appropriate Federal employees, i.e., HUD or DOJ employees, as requested by telephone or written notice through an appropriate Rural Development Official. Boothbay Region Water District Responsibilities Supply of potable water. Installation of meter and meter findings. Applicant Responsibilities Cost of the service line from the water main to the building, plumbing, including excavation, and any permits required (ie., Road Opening) If required, cost of tapping of water main to be reimbursed to the District. Read and comply with the Boothbay Region Water District's Terms and Conditions of Service Release* I/We hereby give the Boothbay Region Water District permission to release any and all information which may be deemed necessary in order for collection of any outstanding debts I/We may occur to the Water District. Terms & Conditions* I have read and understand the above. I have also downloaded a copy of the Terms and Conditions of Service. I authorize the Boothbay Region Water District to enter the premises and access the property to inspect the service installation, normal maintenance of the water meter, evaluate, require and test backflow prevention devices, and evaluate potential usage. I further understand the estimated cost is to be paid in advance and any adjustments will be made upon completion of the work. Billing Agreement* I hereby contract with Boothbay Region Water District for water service and agree to pay for the same in accordance with the established rates of said Water District until written notice is given to discontinue said water service, and to conform to all Rules and Regulations of said Water District, now in force or which may hereafter be adopted, governing the use of water. I understand that should my property ever be rented, and the tenant has water service in their name(s) and fails to make full payment I, as the property owner, am responsible for payment and agree to indemnify and hold harmless the Boothbay Region Water District from any and all debts and costs of collection in connection with said debt. Please Type Applicant Name to Serve as Electronic Signature*Please Type Co-Applicant Name to Serve as Electronic Signature
