Trucked Water Connection Application Form

Connection Date

Name*

First Last

Name

First Last

Civic (Service) Address

Street Address Address Line 2 City Province Postal Code

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (Home)*

Phone (Work)

Phone (Cell)

Invoices via:*

Email - no charge
Mail - $2.50 monthly paper invoice enviro fee

Email Address*

Is the property rented or owned?*

Renter Occupation - Owner/Landlords name and phone number are required
Owner Occupation

Owner's Name

First Last

Owner's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Purchase Date

Previous Owner's Name

First Last

Connection Fees

Connection Fee will be included on the first invoice. Connection Fee: $42.00

Terms and Conditions*

By completing this form, you acknowledge that you are responsible for the completeness and accuracy of the information you provide. Any false or misleading statement with respect to this form and any supporting information required pursuant hereto may result in the denial of your application and refusal of services. All personal information provided on this form is collected by the Town of Hay River for the purpose of determining entitlement of the applicant for the provision of services described herein. In the performance of those services, the personal information is collected, used, and disclosed under the authority of the Access to Information and Protection of Privacy Act and any other provincial laws, regulations, and policies applicable to the protection of personal information. By submitting this form, the applicant consents to the collection, use, and disclosure of personal information by the Town of Hay River for the provision of services. This acknowledgment shall be governed and construed in accordance with the laws of the Northwest Territories.

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Trucked Water Connection Application Form

Connection Fees

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