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RESIDENTIAL WATER APPLICATION

  1. PLEASE CHECK ALL THAT APPLY:

  2. *** GOVERNMENT ISSUED PHOTO ID REQUIRED

    Fax to: (309) 524-2074 Email to: kverbeke@moline.il.us

  3. Optional

  4. I, the undersigned, do hereby represent that I am the OWNER of the legal or equitable title to the premises stated above; in the City of Moline, Illinois or that I hold such legal or equitable title in conjunction with my co-owner.

  5. The undersigned OWNER does hereby GUARANTEE PROMPT PAYMENT when due of all bills for water and/or sewer furnished at the said premises even though not occupied by the said OWNER until said OWNER shall notify the Water Department to terminate such services. This application and acceptance thereof by the City shall constitute a contract between the City; and the undersigned parties, and such contract, shall be subject to all applicable City Ordinances, Rules and Regulations, now in force, or hereafter adopted by the said City or by the Water Department.

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