FIRE HYDRANT METER PROGRAM DESIGNATED AGENT FORM

Fire Hydrant Meter Information Current Date: Account Number:

Company Name:

Business Owner: Phone Number:

Driver's License Number: State Issued: Expiration Date:

Designated Agent: Phone Number:

Driver's License Number: State Issued: Expiration Date:

I hereby certify that I am the business owner or responsible party for the above listed company. I am authorizing to designate the person listed above as my agent in applying for this Fire Hydrant Meter Permit and: A. I have read, acknowledged, and understood the Conditions of Service Agreement given to me with the Fire Hydrant Meter Permit application. B. I am the person ultimately responsible for compliance with all of the terms listed in the Conditions of Service Agreement and the Fire Hydrant Meter Permit. C. I am the person ultimately responsible for the payment of all incurred charges on the Water Authority account created by the Fire Hydrant Meter Program if such permit is granted.

Printed Name of Responsible Party:

Signature of Responsible Party: Date:

**Form will NOT be processed unless all information is complete**

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FOR OFFICIAL USE ONLY

FH Coordinator Printed Name: Approval Date:

FH Coordinator Signature: Supervisor Approval:

Comments:

Created 3.31.15 AMP

State of ________________________________________ County of ______________________________________ Signed and affirmed before me on _________, 20_____ by ____________________________________________ (Seal) Notary Public: ________________________________ My commission expires: ________________________