2. NEWPORT NEWS WATERWORKS
   Tenant Authorization Form

4. Service Address*
5. Effective Date of Tenant*
   Effective Date of Tenant

7. The tenant(s) below has/have entered into a lease agreement for the referenced service address and is/are authorized to obtain services at the address.

9. Tenant Name*
10. SSN or DL#
12. Phone*
13. Email
15. Tenant Name
16. SSN or DL#
18. Phone
19. Email
21. Tenant Name
22. SSN or DL#
24. SSN or DL# Disclosure is voluntary.

    Collection is authorized by VA Code 2.2-3808

26. Property Owner Information
28. Owner Name
30. or
32. Authorized Agent Name

    (if applicable)

34. Mailing Address*
36. City/County*
37. State*
38. Zip Code*
40. Email
42. Phone
44. Check here*

    1. I understand

    You understand that by typing your name below you are electronically signing this document.

46. Signature*
47. Date*
    Date
49. This form must be signed by the legal recorded property owner or authorized property manager.
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit Submit and Print

* indicates a required field