Customer Registration Form For Water And Sewer Billing - New York Department Of Environmental Protection
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1
2
3The City of New York
Department of Environmental Protection
Bureau of Customer Services
59-17 Junction Boulevard
Corona, N.Y. 11368-5107
Customer Registration Form for Water and Sewer Billing
Property Ownership Information:
(1) Property is located in the Borough of:
Block:
Lot:
Meter #
:
(if available)
(2) Service Address
(3) Mailing Address (if different from Service Address)
Street ______________________________
____________________________________
City
______________________________
____________________________________
State, Zip _______ , __________-________
_______ , __________-________
(4) Owner’s Name: Business:
_______________________________________________ OR
Individual: ____________________ ____________________ ____
(Last Name)
(First Name)
(MI)
(5) Owner’s Telephone Number:
Residence: (____)_______-_________
Business: (____)______-_________ x-______
Customer Billing Information:
(Please provide the following information about the customer responsible for paying water/sewer bills at this premise.)
(6) Account Number
: ___________________________
(if available)
(7) Name: Business:
_______________________________________________ OR
Individual: ________________________ _________________ ____
(Last Name)
(First Name)
(MI)
(8) Mailing Address:
Street _______________________________________________________
City _________________________ State ______ Zip _______-______
(9) Relationship of the customer to this premise
: Agent: _____
Owner: _____
Tenant: _____
(check one)
Owner’s Approval:
(The Property owner must approve someone as a customer at this property. The failure by a customer to pay the water/sewer bills will initiate
"Delinquency" actions which may ultimately result in the property being taken over by the City or placed in a lien sale.)
(10)
Owner’s SSN OR EIN_____________________
(11)
____________________________________________________
(Print name and title if applicable)
(12)
_______________________________________________
___/ ____/ ____
(Signature)
(Date)
BCS Customer Registration Form (Rev. 4/00)
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