Connect or Disconnect Utility Services : Service Request Form

Water Service Request Form

Please use the form below for Water Utility Service.  Once you click the submit button below your request will be sent to the District's Customer Service Department and a Customer Service Representative will respond within one business day.

Name (last, first):   
Main Phone:   Home   Work   Cell
Alternate Phone:     Home   Work   Cell
Driver License # or Tax ID: State: 
Your Email Address:
 

Property Type:      Residential         Commercial 

Service Request Information:      New        Final        Transfer*
    * Please note:  Transfer is to be used if you currently have service with BCMUD
       and are moving to another property within our service area.  
Service Request Date:   

Service Address:     City:    
                               State:      Zip: 

Billing Address: 
   Same as above
   See below **
  
Forwarding Address - See below **

   ** Billing Address:    City: 
                                  State:      Zip:     

 

Authorized Account Individuals:
   Name:     Phone(s):      Home Work Cell
   Name:     Phone(s):      Home Work Cell
   Name:     Phone(s):      Home Work Cell

   

Have you previously been a resident of the Brushy Creek MUD?   Yes   No 

If disconnecting, will this property be maintained by you for investment and/or rental purposes?    Yes   No 

 
   
 

Privacy Act: 

I (we) request that under the Privacy Act, the District not release any information:  Initials: 

Signature:      Date:  

Please note:  Request made will be processed twenty four (24) hours after contact by BCMUD and payment (Deposit / Admin Fee) is made.  Service request can only be made Monday - Friday except for Holidays and extenuating circumstances. 

 

Notes: