Golden Isles LEPC

MAR Application For Service

    Have you ever had a MAR account with the JWSC before?

    If yes, account number:

    What is the purpose of your application? Describe project:

    Have you spoken with JWSC staff to request testing?

    If Yes, Staff Name:

    What type of MAR account are you requesting?

    Additional Items Needed When Submitting Application:

    Applicant Information

    Corporate or Business Name:

    Doing Business As:

    Start Date Of Business:

    Business License Number:

    City/County:

    This Is A:

    If Corporation or Partnership: (Principal Officers)

    Billing Address:

    Bill Delivery Method:

    Primary Phone:

    Work or Cell:

    E-Mail Address (To Send Billing Statement):

    E-Mail Address for Test Results:

    Responsible Party (Owner/Officer):

    Date of Birth:

    Driver’s License #:

    State:

    Additional Person Authorized on Account (No Signature Required):

    Septic Hauler Truck Information

    Septic Hauler Truck Number:

    Septic Hauler Tank Capacity:

    Septic Hauler Tag Number:

    Additional Hauler Truck Information

    Septic Hauler Truck Number:

    Septic Hauler Tank Capacity:

    Septic Hauler Tag Number:

    Document Uploads

    Required Documents:

    Additional Document 1:

    Additional Document 2:

    Additional Comments

    The undersigned hereby request provision of service by Brunswick-Glynn Joint Water and Sewer Commission, as described hereon, for which I agree to pay when invoiced at the scheduled rate then in effect when due. I will comply with the rules and regulations of the JWSC making them a part of this agreement. In the event of default of payment, the ordinances of the JWSC will apply and any fees assessed for such default will be my responsibility. If I fail to comply with this agreement, or any part thereof, the JWSC may withhold testing results, discontinue sewer services to the premises without notice to me, and/or refer the delinquent account to a third-party debt collection service. The JWSC reserves the right to contact the applicant hereon at any of the project locations described herein.

    Signature of Applicant:

    Date: