Hickory Kerton Water Co-op
315 N. Monroe St. Rushville, IL 62681
217-322-6533
                                 
                                             Account Number_________
Application for Membership and Water Supply

	 The undersigned (hereinafter called the Applicant) hereby applies for membership in the HICKORY-KERTON WATER CO-OP(hereinafter called the Co-op), and the Applicant and the Co-op agrees as follows:

1.  The Applicant agrees to pay the sum of $50.00 for membership subscribed for by the Applicant, a Certificate for which will be issued to the Applicant upon acceptance of the application by the Co-op.
2.  When Co-op makes water supply available to Applicant, Applicant agrees to purchase from the Co-op, and pay monthly to the Co-op for all water supply used on premises now owned or occupied by the Applicant, in accordance with the rate schedule and rules and regulations established by the Co-op and agreed upon by Rural Development.
3.  When application is for joint membership, the Applicants are jointly and severally bound by the terms of this application and agreement, as defined by the bylaws of this Co-op. One membership is entitled to one vote.
4. The Applicant will comply with and be bound by the provisions of the Articles of Incorporation, the Bylaws, the Policies and Regulations of the Co-op as may be adopted from time to time. The Applicant also agrees to provide an easement for a water main to cross his/her property.

	The acceptance of this application by the Co-op shall constitute a contract between th applicant and the Co-op. Unless otherwise specified, the contract for water supply shall continue in force for one year from the date service is made available by the Co-op to the Applicant and thereafter until canceled by written notice given by either party to the other at least (30) days in advance.

Dated________________                  Applicant____________________________________________

Phone:(____)_______________        Applicant____________________________________________

                                                           Address______________________________________________
                                                                        ______________________________________________

                                              Billing Address_______________________________________________
                                                                       _______________________________________________

If applicant does not own property, name and address should be given on lines below:

Name of Landlord__________________       Address________________________________________
                                                                                      ________________________________________
The Above application for membership accepted this____day of___________________, ___________
HICKORY KERTON WATER CO-OP     By:______________________________________________

For Statistical Purposes Only:(optional)
White, not of Hispanic Origin____;Black, not of Hispanic Origin_____;American Indian or Alaskan Native_______;Hispanic_________;Asian or Pacific Islander___________