Sewer Account Number:(Required)Account Name:(Required)Service Address:(Required)Service Address City, State, Zip Apache Junction, AZ 85119 Apache Junction, AZ 85120 Mailing Address Street:(Required)Mailing Address City:(Required)Mailing Address State:(Required)Mailing Address Zip:(Required)Phone Number:(Required)Email:(Required) Effective Date of this Request: Authorized Person 1:(Required)For Account Verification: Authorized Person 1 (Last 4 of SSN) or (Date of Birth)(Required)Authorized Person 2:For Account Verification: Authorized Person 2 (Last 4 of SSN) or (Date of Birth)Authorized Person 3:For Account Verification: Authorized Person 3 (Last 4 of SSN) or (Date of Birth)By electronically signing this form, I hereby authorize Apache Junction Sewer District (the "District) to release account information upon request to the person(s) named. I understand that disclosure may be in the form of, but not limited to copies of monthly statements, copies of delinquent or disconnection notices, customer correspondence and/or verbal communication. I acknowledge that the authorized person(s) is not recognized as my legal representative and does not have legal power of authority to make changes to the account. I have been advised that the District will not provide any notification to me when information is released. I assume responsibility for notifying the District if, and when, it should become necessary to revoke this authorization.(Required) I agree to the terms and conditions stated above and I understand by checking this box and typing my full name below, this constitutes a legal signature as the owner of the above mentioned property.Signature: (Please type your full name.)(Required)
