Form Center

2. Account Number*
3. Date to Start Service*
   Date to Start Service
5. Location Address*
7. Legal Description
9. Mailing Address (If Different)
11. Previous Address
13. Number of Persons Occupying Premises
14. Sewage Disposal

    1. City

    1. Septic
16. If this is a rental property, homeowner's name:
18. If this is a rental property, please request a Supplemental Users Agreement to fill out.
22. Name*
23. Email
25. Home Phone
26. Cell Phone
28. Employer
30. Employer Address
32. Work Phone
36. Spouse / Co-Occupant Name
37. Cell Number
39. Employer
41. Employer Address
42. Phone Number
44. Have you ever had service with us?

    1. Yes
    2. No
46. When / Location
48. Personal Reference*
49. Phone*
51. Users Agreement
    Water, Sewer, Waste Disposal Users Agreement (PDF)
52. Agreement Signature*

    I agree to comply with and be bound by all rules and regulations of the Piedmont Municipal Authority and to pay any and all fees, assessments and other lawful amounts chargeable by members.

    1. I agree.
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field