Request for New Service


Privacy

Loudoun Water will respect our customers' right to privacy on this website. The information you submit will remain confidential and will not be sold or used by an outside company. However, information provided by visitors to this site may be used internally to enhance our website and improve customer service.

You may start water and sewer service with Loudoun Water by completing and submitting this form. In order to avoid delays please make sure you that you accurately complete the required information below. If you have any problems submitting your form or if you have any questions regarding service, please call 571.291.7880.

A $25 Service Account Setup Charge Will Appear On Your First Bill.

 * First Name:  
 Middle:   
 * Last Name:  
 * Primary Phone:  
 * Work Phone:  
 SSN:   
 * Email Address:  

 Service Address
 * Address:  
 * City:  
 * State:        
 * Zip Code:  
 * Primary Phone:  
  Work Phone:  
 Work Phone Ext.   

 Billing Address
(if different from the service address)
 Address:  
 Address 2:   
 City:  
 State:        
 Zip Code:  
 Primary Phone:  
 Work Phone:  
 Work Phone Ext.   

 Please select the appropriate box
 Regarding the property,
 will you be the:		    
If tenant is selected, then the following information is required:

Owner/Landlord
 First Name:  
 Middle:   
 Last Name:  
 Address:  
 Address 2:   
 City:  
 State:        
 Zip Code:  
 Primary Phone:  
 Work Phone:  
 Work Phone Ext.   

Start Service Date:

We need a minimum of 24 hours notice to start service Monday-Friday and we are closed on weekends and holidays. Call us by 5 pm on a Friday to start service on a Monday.

   Wednesday, June 03, 2009 Select a Date Delete the Date 

Did you have previous service with Loudoun Water?

Former Address: 
  
What year did you live there?
  

Information Provided By:
* Name:    
  
* Primary Number:
  
Relationship (if not the customer):
  

    
*  Privacy and Terms of Use Agreement

(*) Required Information

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