Trucked Water Disconnection Application Form

Disconnection Date*

Final invoicing and billing amount will be issued the following month of the disconnected date.

Name*

First Last

Name

First Last

Civic (Service) Address*

Street Address Address Line 2 City Province Postal Code

Forwarding Address

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

Phone (Home)*

Phone (Work)

Phone (Cell)

Email*

Equal Payment Plan will be cancelled if applicable*

Yes
No

Last Payment Date

A Disconnection Fee of $42.00 will be included on your final bill.

Is this property rented or owned?*

Renter Occupation
Owner Occupation

Owner Name

First Last

Sale Date

New Owner's Name

First Last

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.”

I Agree

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Trucked Water Disconnection Application Form

Resources

Town of Hay River

Connect With Us

Popular Links