Water & Sewer Move Out Work Order Form

Name (as shown on utility bill): *

Service address: *

Holland Charter Township account number:

Phone number: *

Cell number:

E-mail: *

Final my account as of (date): *

Please enter the final date that your account should be billed

Street address: *

City *

State *

ZIP *

Please confirm you have received and processed my Move Out Work Order by:

Calling me

E-mailing me

Comments: