Application for a New Account
                                               Corbett Water District
                                     36120 E. Historic Columbia River Hwy.
                                          PO Box 6  Corbett, OR 97019
                                                   (503) 695-2284

Date service to start: _________________      Account #: _______________________

Applicant Name:_______________________________________________________

Street Address of location:________________________________________________

Mailingaddress_________________________________________________________

City: ___________________State: _________Zip:_____________________

Home Phone #:__________________ Alternate Phone #:________________________

Work Phone: ________________________   Email:____________________________

Drivers License #:_______________________

Employer:_____________________________________________________________

Landlord Name (if rental):_________________________________________________

Landlord Address_______________________________________________________

Landlord Phone #:_______________________________________________________

The landlord needs to be aware that if the renter’s water bill is not paid the landlord is responsible. The water service will not be restored until the amount of the water bill is paid in full.

Landlord signature:____________________________________  Date:_____________

Emergency Contact:_____________________________________________________

Phone #:_______________________Relationship: _________________________

I hereby request that Corbett Water District furnish water to the above premises of which I am owner/tenant.  I agree to pay the regular rates and charges for water service at these premises and to abide by all rules and regulations proclaimed by the Board of Commissioners of the Corbett Water District as of now or hereafter in effect. 

Signature:_____________________________________Date: ___________________

To open a new account with Corbett Water District you are required to provide a $120.00 deposit. This deposit is held until the time the customer leaves residence and the account is closed. At which time the deposit will either be applied to the final bill or if the balance has already been paid it will be refunded via check only. Please remit a $120.00 deposit with your application.