Tenant (Renter) Application

Service Address

Service Address City, State, Zip

Service Effective Date

Primary Applicant Name

Primary Applicant Social Security Number

Primary Applicant Date of Birth

Primary Applicant Telephone Number

Primary Applicant Email Address

Co-Applicant Name

Co-Applicant Social Security Number

Co-Applicant Date of Birth

Co-Applicant Telephone Number

Co-Applicant Email Address

Owner Name

Owner Phone Number

Owner Email Address

Is your mailing address the same as your service address?

Mailing Address

Mailing Address City, State Zip

Previous Service Address

Previous Service Address City, State Zip

Would like to signup for Preauthorized Payments ?

Pre-Authorized Payments Routing Number

Pre-Authorized Payments Acount Number

Disclaimer As the tenant of the real property listed above, | understand I am responsible for any unpaid debts that may accrue through the use of the District water consumed on the property. I acknowledge and agree that a lien may be placed on the property should these debts remain unpaid. I am aware that if a delinquency occurs on one account, all accounts held are subject to disconnection. I am aware that the owner will be notified may a lien be placed on the property. I am aware that at the appropriate time, it is my responsibility to contact the District to close my account.

Applicant Name

Applicant Phone Number

Applicant Signature

Date Signed

Applicant Drivers License / ID

Co-Applicant Drivers License / ID

Rental Agreement, Lease Agreement, or City of Beaumont Tenant Authorization Letter