Residential Application for Service

This service request form is intended to help you set up a new single-family residential account. Non-residential service accounts require more details to determine the required deposit. Please contact Tiffany Tiner, Service Review Specialist, at 912-261-7139 or email for non-residential accounts.

Our service application form is also available for download here:  Application to Start Service

Following receipt of this form, staff will contact you by phone during regular business hours to get Social Security Number (or Tax ID Number), payment information for the required deposit and account setup fee, and to confirm date and time for turning on the service. Failure to respond to our follow-up contact may result in delays in processing.

Same-day service may not be guaranteed for requests received after 12:00 pm using this form.

All required fields below must be completed and a government-issued photo ID matching the responsible party listed on the account must be attached in order to process the application. A utility bill showing your name and the new service address is required to validate the responsible party.

The following form may not work correctly using Internet Explorer or Safari. Please use Edge, Firefox or Chrome if possible.

Have you previously had water/sewer service with the BGJWSC?

Service Address Information

Primary Applicant Information

Billing/Forwarding Address, If Different from Service Address (not required)

Co-Applicant Information (not required)

Additional Persons

Landlord Contact Information (required if property not owned)

Acceptance of Conditions

I hereby request provision of water and/or sewer service by Brunswick-Glynn Joint Water and Sewer Commission for the premises described herein for which I agree to pay monthly at the schedule rate then in effect when due. I will give notice to the JWSC of my vacating or selling said premises. I will comply with the rules and regulations of the JWSC making them a part of this agreement. In the event of default of payment, the ordinances of the JWSC will apply and any fees assessed for such default will be my responsibility. I agree to claim no damage on account of the stoppage of the flow of water or sewer resulting from accident or the making of alterations, repair or improvement by the JWSC. I agree to keep all plumbing on the premises in repair and promptly stop all leaks. If I fail to comply with this agreement, or any part thereof, the JWSC may turn off the water and/or discontinue sewer services to the premises without notice to me. The JWSC reserves the right to contact the applicant herein at any of the locations described herein.

To reduce the risk of identity theft, you must include the following item: