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2. 
4. 776 NE 125 Street, P.O. Box 619085, North Miami, Florida 33161-0850
   305-895-9880
6. Date
   Date
8. Name
   Please print individuals, companies, or corporation's name.
9. Email Address
11. Mailing Address
13. City
14. State
15. Zip Code
17. Phone Number
19. Address of Proposed Connection
21. City
22. State
23. Zip Code
27. Check type of construction water meter will serve:

    1. New Construction
    2. Single Residence
    3. Apartment
    4. Commercial

    1. Existing
    2. Duplex
    3. Motel
    4. Other
29. # of Baths
30. Sq. Footage
34. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
36. Electronic Signature
38. Company Title
42. Meter deposit amount is $2,000.00. The minimum monthly fee is $274.86, which is subject to change without notice.
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit Submit and Print

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