Water Works District No. 3 of Rapides Parish

Date*

Last Name*

First Name*

M.I.

Email*

Phone Number*

Service Address*

City*

State*

Zip*

Mailing Address*

City*

State*

Zip*

Social Security Number*

I understand if I do not wish to give my Social Security Number and I am due a refund, I may not receive it if I cannot be located.

Has Water Works District No. 3 ever provided water service for you? Yes No

If Yes, Where?

City

State

Zip

When

Do You Own Rent

If renting, Landlord's Name

Today's date:

Date service requested to begin

For same day service, applications must be received according to the following schedule:
Time 8 a.m.-11 a.m. must be received before 8:30 am Monday – Friday.
Time 12:30 p.m. - 3 p.m. must be received before noon Monday – Friday.

Time selection 8 am - 11 am 12:30 pm - 3 pm

I understand that someone must be at the service address during the time indicated or the water may not be connected. An additional $35 will be added if a return trip is necessary.

The undersigned hereby requests Water Works District No. 3 of Rapides Parish to render water service at the above service address, grants to the District the necessary right-of-way for the extension of such service which is binding upon the undersigned's heirs or assign, and agrees to receive from and pay the District all such services required on the premises at above service address, in accordance with applicable rates and with the service regulations of the Water District.

The Water Works District No. 3 of Rapides Parish has "Intergovernmental and Cooperative Endeavor Agreements" in effect with the City of Pineville, Town of Ball, and Rapides Parish Sewerage District No. 2, that allow termination of your water service for failure to pay your public utility/services bill from those agencies. Those public utility/services bills must be paid directly to those agencies and Water Works District No. 3 of Rapides Parish cannot accept any payment for those utility/services bills.

Please provide a copy of your drivers license and/or photo ID:

If you are unable to provide a photo ID at this time, please fax it to 318-641-9223 at your earliest convenience.

Applicant's Signature*

Date*

Submit

Water Works District No. 3

Residential

Please provide a copy of your drivers license and/or photo ID:

Thank you for your information. We will get back to you soon.