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City of Buckner
Meter Application


___Rent:
Landlord’s Name:  
Phone:
 
___Own
  


Service Address:                                                                                                         Name:      
Phone Number(s):      
SSN #:
Date of Birth:
ID Number:  

Employer:   
Employer’s  Address: 
Employer’s Phone Number: 

Spouse’s Name: 
SSN #:
Date of Birth:
ID Number:  

Employer:   
Employer’s  Address: 
Employer’s Phone Number: 

Preferred Billing Address:  

AUTHORIZATION:
I agree that I have applied for utility services provided by the City of Buckner, Missouri and I am responsible for any and all amounts billed to me by the City of Buckner, Missouri. I agree that if necessary that the City of Buckner has the right to turn over to collections or file suit on any past due water bills. I hereby certify that I have read and examined this agreement and know the same to be true and correct. All provisions of laws and ordinances governing service will be complied with.

Signature: Date:  



OFFICE USE ONLY:


Account Number:  

Date Activated:  


Date of Deposit:
Deposit Amount
Type:
Receipt #: