Beckley Water Residential Water Sign Up

Name*

First NameMiddle NameLast Name

Email*

example@example.com

Spouse/Other Family Member

Name of Spouse or other person at requested service address

Daytime Phone Number*

Other Phone Number

Date of Birth*

MonthDayYear

SSN (Last 4 digits) or EIN*

Drivers License # *

Drivers License or Government Issues I.D. Number

State Issued*

Government Issued ID*

Browse Files

Address of Service*

Street Address

Street Address Line 2

CityState

Zip Code

Requested Service Date*

Allow 48hrs after form submission

Is Water Currently On at this Service Location?*

YESNONOT SURE

Do you know current customer's information at this service address?*

YESNO

Current Customer's Name

First NameLast Name

Customer Mailing Address*

Same As AboveDifferent Mailing Address & Service Address

Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Do you have City Wastewater or Septic?*

City WastewaterPrivate Septic

Sanitary Sewer (Wastewater)*

Sanitary Sewer Account Number*

Type in account number including dashes

Sewer Department Receipt*

Browse Files

Upload a scan or clear picture of your receipt

I understand and agree that selecting this option, my water will be terminated if found to be on City Sewer. Furthermore, I am responsible for any water used, any and all billing amounts accrued during time of service.*

APPLICATION FOR WATER SERVICE

CUSTOMER SERVICE ADDRESS

CUSTOMER MAILING ADDRESS

Wastewater - City or Private

If previous Beckley Water customer, please include the following: