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2. Account Name*
   Enter the name you want on the water account
4. Upload ID*
   Please upload a copy of a valid government-issues photo ID for this person.
6. Additional Account Name*

   1. Yes
   2. No

   Do you want to add a second name to this account?
8. Additional Name*
   Enter the additional name for this account.
10. Upload ID*
    Please upload a copy of a valid, government-issued photo ID for this person.
12. Service Address*
    Enter the street address where you need water service (street number and name only)
14. Date to Start Service*
    Date to Start Service
    Enter the date you need service to begin at this address. Dates must by Monday through Friday and not be a holiday.
16. Billing Address*

    Do you want your bill sent to the service address?

    1. Yes
    2. No
18. Billing Address
    Enter the billing address for this account.
20. City
21. State
22. Zip Code
24. Phone Number*
    Enter your phone number.
26. Email Address
    Enter your email address.
28. Own or Rent*

    1. Own
    2. Rent

    Indicate whether you own or rent this property.
30. Lease Agreement*
    Please upload a copy of your entire lease agreement.
32. Sprinkler System*

    1. Yes
    2. No

    Is there a yard sprinkler system installed at the home?
34. Bill Delivery Preference*

    1. Regular Mail
    2. Email
    3. Both

    Indicate if you prefer to receive your bill via postal mail, email or both.
36. Email Address*

    Enter the email address where you'd like your bill sent.

40. RESIDENTIAL DEPOSIT INFORMATION
    A minimum deposit of $200 is required for each residential account and must be paid before water can be turned on at an address. Deposits shall be applied to final bills when water service is terminated, with any credit balance remaining returned to the account holder. If an acceptable Letter of Credit from a previous utility reflecting a good payment history is provided within 15 days of the date of the service application date, then half of the deposit ($100) will be credited back to the water account. It is the customer's responsibility to ensure that the Letter of Credit is received within the 15 day period. An acceptable Letter of Credit must be printed on the utility's letterhead. Printouts of account payment activity cannot be used as a Letter of Credit. Payment history must show no more than (2) late payments in the last 12 months and no disconnections due to non-payment. The Letter of Credit must be in the same name as the BWA Service Application.
42. Payment of Deposit
    Once your service application is received and processed you will receive an email from BWA with instructions on how to pay your deposit.
44. Deposit Requirements *

    1. I have read and understand the deposit requirements.
48. SERVICE AGREEMENT PURPOSE. The BENBROOK WATER AUTHORITY (BWA) is responsible for protecting the drinking water supply from contamination or pollution which could result from improper system construction or configuration on the retail connection owner's side of the meter. The purpose of this service agreement is to notify each customer of the restrictions which are in place to provide this protection. The public water system enforces these restrictions to ensure the public health and welfare. Each retail customer must sign this agreement before the BWA will begin service. In addition, when service to an existing retail connection has been suspended or terminated, the water system will not re-establish service unless it has a signed copy of this agreement. RESTRICTIONS. The following unacceptable practices are prohibited by State regulations. A. No direct connection between the public drinking water supply and a potential source of contamination exists. Potential sources of contamination are isolated from the public water system by an air gap or an appropriate backflow prevention assembly in accordance with Commission regulations. B. No cross-connection between the public drinking water supply and a private water system exists. Where an actual air gap is not maintained between the public water supply and a private water supply, an approved reduced pressure principle backflow prevention assembly is properly installed and a service agreement exists for annual inspection and testing by a certified backflow prevention assembly tester. C. No connection exists which would allow the return of water used for condensing, cooling or industrial processes back to the public water supply. D. No pipe or pipe fitting which contains more than 8.0% lead exists in private water distribution facilities installed on or after July 1, 1988 and prior to January 4, 2014. E. Plumbing installed after January 4, 2014 bears the expected labeling indicating ≤0.25% lead content. If not properly labeled, please provide written comment. F. No solder or flux which contains more than 0.2% lead exists in private water distribution facilities installed on or after July 1, 1988. III. SERVICE AGREEMENT. The following are the terms of the service agreement between the BWA (Water System) and the Customer. A. The Water System will maintain a copy of this agreement as long as the Customer and/or the premises is connected to the Water System. B. The Customer shall allow his/her property to be inspected for possible cross connections and other potential contamination hazards. These inspections shall be conducted by the Water System or its designated agent prior to initiating new water service; when there is reason to believe that cross connections or other potential contamination hazards exist; or after any major changes to the private water distribution facilities. The inspections shall be conducted during the Water System's normal business hours. C. The Water System shall notify the Customer in writing of any cross connection or other potential contamination hazard which has been identified during the initial inspection or the periodic re-inspection. D. The Customer shall immediately remove or adequately isolate any potential cross connections or other potential contamination hazards on his/her premises. E. The Customer shall, at his/her expense, properly install, test, and maintain any backflow prevention device required by the Water System. Copies of all testing and maintenance records shall be provided to the Water System. IV. ENFORCEMENT. If the Customer fails to comply with the terms of the Service Agreement, the Water System shall, at its option, either terminate service or properly install, test, and maintain an appropriate backflow prevention device at the service connection. Any expenses associated with the enforcement of this agreement shall be billed to the Customer.
52. Electronic Signature*

    1. I agree

    By checking the "I agree" box above, you agree and acknowledge that 1) your application and service agreement will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
54. Electronic Signature*
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field