Authorized Individual

Authorized Individual Form

Pursuant with Arkansas Code §25-19-105(b)(20), the following listed authorized individual(s) may act as my representative for the following account(s) with Springdale Water Utilities. The authorized individual(s) may obtain billing and usage information, make payments, or conduct inquiries regarding my account with the exception of transferring or terminating service.

Account Number: *

Name on account: *

Last 4 digits of Account Holders DL # (or Tax ID # if commercial): *

Please verify last 4 digits of account holders drivers license number.

Service Address: *

Apt, suite, etc:

Email:

Phone Number: *

Name of Authorized Individual: *

Authorized Individual DL#: *

Upload Color Copy of DL:

A front sided color copy of current government issued photo ID is required to set up service | Acceptable file types: .bmp, .gif, .jpeg, .jpg, .doc, .docx, .odt, .pdf, .png, .tif, .tiff

E-Signature: *

Date: *

You may terminate this authorization at any time by contacting customer service 479-751-5751.

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Authorized Individual

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