52 Winthrop Street, Hallowell, Maine 04347
                                                                  WWW.HALLOWELL WATER DISTRICT.COM

NAME                                                                         (owner)                DATE                                       


I am requesting   WATER  service at the above location .                          yes       no    

I am requesting   SEWER  service at the above location .                          yes       no    

*    I understand that as the owner, I am responsible for all bills assessed to this location by the Hallowell Water District. 
*    I acknowledge receipt of a copy of the water and sewer rates.
*    I agree to abide by all the rules, regulations, and policies of the District and I agree to abide by all the applicable rules
      and regulations of the State of Maine, Public Utilities Commission.  If a conflict arises between the Hallowell Water
       District rules about water service issues and the Maine Public Utilities  Commission's rules, the Commission rules shall
*    I agree to accept service at the pressure and quality available in the area.
*    I agree to notify the District of any change in use of the property.

MAILING ADDRESS                                                                                                                          

CUSTOMER CLASS :              RESIDENTIAL   COMMERCIAL            % of comercial use                        

               signature  (owner)                                                     telephone number

IS THIS RENTAL PROPERTY     yes       no                If "YES" how many units