Free Water Conservation Kit Program

Free Water Conservation Kit Program
CK #
Applicant Information:
Utility*
First Name*
Last Name*
M.I.
Street Address*
Unit #
City*
Zip Code*
Relationship to property*
U.S. Phone
Email*
example@example.com
Mailing Address (if different from above)
Agreement of Terms and Conditions
The undersigned agrees to hold harmless the Utility and/or Polk Regional Water Cooperative against all loss, damage, expense, and liability resulting from the loss, destruction or damage to property arising out of or in any way connected with the installation of the Water Conservation Kit. The Utility reserves the right to alter this program at any time. Program funding is limited to available resources. For further questions, please call your Utility.

I have read, understand, and agree to the terms and conditions of this program.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Complete, sign and date this page. Incomplete applications will be denied and returned.
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