City of Greensburg Water Wastewater - Application For Service

Primary  Applicant: 


Social Security  Number 
or Federal Tax ID:


Place of  Employment: 


Place of  Employment  Telephone  Number: 


Customer  Telephone  Number:   


Service Address: 


Billing Address if  Diff than Service  Address: 


Secondary  Applicant: 


Social Security  Number: 


Place of  Employment: 


Place of  Employment  Telephone Number: 


Number of People  in Household: 


Contact Person: 


Contact    Telephone    Number:   


Own or Rent?:   


Owners Name if  renting:


Street Address: 


City, State 
Zip Code: 


Phone Number: 


Lease Term: 


Service Start  Date: 


Application Date: 


Cell Phone  Number:


Email Address:



By signing this application (in person or authorizing by phone, fax or email), the primary applicant agrees to pay and be responsible for all water, wasterwater and sanitation charges, regardless if consumption is used. Charges start on the date specified in the "Service Start Date" area on this application and end on the date specified by the consumer either by phone, in person, fax or email, or if the account appears on the disconnect list the second consecutive month. In the event there is a secondary applicant, they will have equal responsibility for said charges. In the event a primary or secondary applicant wishes to be removed from their account, they must phone this office at 812.663.5621 during normal business hours with a date to have their name removed and provide us with an address for any future correspondences. Deposits will remain with the account until both applicants have vacated the service address. If a final bill has been left unpaid, the remaining name or names on the account bear total responsibility. Any unpaid balances and a deposit double the normal amount must be paid before new service will be activated. The consumer will be responsible for any litigation expense incurred in collecting bad debt. Interest will not be paid on deposits. Bills are due the 17th of each month. Failure to receive billl does not excuse payment.


Applicant Full   Name (Electronic   Signature): 

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