Following receipt of this form, staff will contact you by phone or email during regular business hours to confirm date and time for turning on the service at the new location. 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 confirmation showing your name and the new service address is required to validate the responsible party.
There will be a transfer service charge of $55.00 billed on your next monthly statement.
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Previous Service Address Information (required)
New Service Address Information (required)
Primary Applicant Information (required)
Billing/Forwarding Address, If Different from Service Address (not required)
Co-Applicant Information (not required)
Landlord Contact Information (required if property not owned)
Would you like to sign up for paperless billing?
YesNo (or already signed up)
Service Turn-On Waiver of Liability and Hold Harmless Agreement
Would you like to have your service turned on while no one is present at the property?
By checking yes above, you understand that it is the BGJWSC preference to turn on water service only when the customer is present. Notwithstanding this, you request and authorize the BGJWSC to turn water service on without your presence at the property listed above. You will ensure that all water connections are properly closed, including but not limited to all interior and exterior water faucets, sinks, tubs, showers, toilets, appliances and all other such connections on the premises. You acknowledge that BGJWSC staff will turn on service giving no attention to continuous water flow through the meter.
You understand that the BGJWSC will not assume responsibility for any leaks or overflows of fixtures or appliances or any damage resulting from any such leaks or overflows and you therefore agree to hold the BGJWSC, their commissioners, employees, and agents, harmless for any and all damages that may result from the actions outlined herein. You further understand that the BGJWSC is immune from liability resulting from damage that may be caused by this activity and that this waiver will not alter this immunity regardless of its enforceability. Furthermore, you agree that the BGJWSC and their employees shall not be held responsible or liable for any injury, damage, or loss in any case whatsoever to the undersigned as a customer for merchandise, property, personnel or for lost income from water service turn-on in your absence.
You further understand that service is not conditioned upon the execution of this document, but instead that this Agreement is required by the BGJWSC when the customer requests the BGJWSC to act contrary to their preferred practices in performing work outside of the presence of the customer.
Additionally, you understand that no billing adjustments will be allowed for any water loss except those that qualify under the terms of the existing leak adjustment ordinance.
You have read this Waiver of Liability and Hold Harmless Agreement and fully understand its provisions. You acknowledge that you are the legal owner of the above-identified premises or have been bound to terms of a formal lease agreement with the legal owner and that you are agreeing to this document of your own free and voluntary act, without any duress, coercion or threats by any person. You also declare that no other person’s consent is necessary to authorize the execution of the Agreement.
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: