2. Company Name*
4. Address*
6. City*
7. State*
8. Zip*
10. Person Responsible for Accounts Payable*
    Customer accounts will be invoiced monthly for all water purchased at the Station. Invoices will include all applicable fees and charges for the gallons of water supplied to the customer as measured by the Station.
12. Email
13. Phone
15. Number of Accounts Requsted*
17. Vehicle License Plate Numbers and/or Names of Individual Account Holders
    When your account is established you will receive a six (6) digit account number that will be used for PIN access at the Station. You may set up multiple accounts if you wish to track individual users or vehicles. The City maintains no responsibility for ensuring proper use of account PINs. PINs may be deactivated at any time by contacting Customer Service during regular business hours at (785) 587-2480.
19. Person Completing Request Form*
20. Phone*
22. Email*
23. Title*
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field