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2. City of Fort Walton Beach

   Finance Department - Customer Service Division

   107 Miracle Strip Parkway SW * Fort Walton Beach, FL 32548

   Phone 850-833-9500 
   Main 850-833-9591  Fax 850-833-9640

   Monday through Thursday 7 am to 5 pm  Friday 7 am to 11 am.

4. Service Location *
6. Service Start Date
   Service Start Date

   (No Saturdays, Sundays, or Holidays)

8. Type of Service*

   1. Cleaning
   2. Full Service
10. Customer Name*
12. I am the *

    1. Property Owner
    2. Tenant
    3. Property Manager/Agent
14. Billing Address*
16. City*
18. State*
19. Zip*
21. Phone*
22. Email*
24. Paperless Billing*

    1. Yes
    2. No
26. Employer*
27. Work Phone*
29. Water Service Agreement

    The City of Fort Walton Beach welcomes you as our new utility customer. We appreciate your business and pledge to do our best to provide exceptional customer service. Because open faucets and/or damaged fixtures, water pipes, and other factors can cause water damage on the premises once water is turned on, the City recommends that the property owner, tenant, or property manager/agent be at the property when service is activated.

    The City is not responsible for any damages resulting from activating water service at your premises. The City rejects all responsibility and/or obligation to determine the condition of the water system on the owner/tenant side of the meter. The undersigned expressly assumes all responsibility and all liability for any damage to the premises, or that of others, resulting from the activation of water service. The undersigned agrees to indemnify and hold harmless the City of Fort Walton Beach for any resulting damage to the premises or to the property of others, which may arise from the activation of water service.

    The Guarantor(s) understand they are responsible for all collection costs and attorney's fees as a result of past due collection efforts being made by the City or its agent as a result of non-payment by the Guarantor(s).

    And furthermore, the Guarantor(s) do hereby authorize and empower any attorney of any court of record of the state of Florida or elsewhere to appear for and to enter judgment against us, or any of us, in favor of FINAL BILL for water service rendered for any sums due under the Agreement plus collection cost, interest with costs of suit, release of errors and reasonable attorney's fees.

31. Today's Date*
    Today's Date
33. Signature*
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