Customer Application Form "*" indicates required fields Account #* HiddenToday’s Date Month Day Year Effective Date* Month Day Year Service Address* Street Address Address Line 2 City ZIP Code Legal Description*Subdivision: Lot: Block:Subdivision: Lot: Block: Owner Name* First Last Spouse/Other Name First Last Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone NumbersOwner Cell*Home PhoneWork PhoneOther CellOther Home PhoneOther Work PhoneEmergency ContactPlease specify preferred method of contact for Emergency* Text Email Phone Number For Texts*Email* # of Living Units*# of People*Do you currently have a sprinkler/irrigation system?* Yes No I hereby agree to receive water service supplied by North Kootenai Water and Sewer District at the service address identified above. I agree to pay for water service at the rates established by the District until notice is provided to the District to discontinue service. I understand a refundable $50 deposit is charged for all new accounts. I understand failure to pay my bill will result in additional charges and discontinuation of service if unaddressed within 60 days of bill origination. District rates, fees, and charges are posted at www.nkwsd.com. I understand that should I rent the property, I am responsible for paying all charges and delinquent fees not paid by the renter or lessee. I agree to provide an approved backflow device on unprotected cross-connections at the service including irrigation systems. I agree to have the assembly tested upon installation and annually each Spring before the irrigation system is charged with potable water by an Idaho-licensed backflow assembly tester. I understand failure to provide adequate backflow protection or failure to provide an annual passing backflow assembly test may result in the discontinuation of water service until the issue is resolved. In the event an individual booster station is desired, it must be pre-approved in writing by the District Manager. NKWSD has adopted water conservation measures. Mandatory non-irrigation hours are from Noon to 6:00 pm between June 1st and September 30th. Property Owner’s Signature*NameThis field is for validation purposes and should be left unchanged.