New Service - Plant Standpipe
This form is to establish service at our Plant Standpipe in Aguila, AZ
Rows
Account Number
Meter Reading
Business Name
Business Name
Tax ID Number
Tax ID Number
Email
example@example.com
Name
*
First Name
Last Name
Title
Title
Driver's License or State Issued ID Number
*
Please include the issuing state
A copy of your Driver's License or State Issued ID is required
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Primary Phone Number
*
Please enter a valid phone number
Format: (000) 000-0000.
Primary Phone Type
*
Please Select
Home
Cell
Work
Secondary Phone Number
Please enter a valid phone number
Format: (000) 000-0000.
Secondary Phone Type
Please Select
Home
Cell
Work
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When would you like to begin Drawing Water?
*
-
Month
-
Day
Year
Date
Additional Comments or Information
Additional Comments or Information
Signature
*
By signing you agree to the Terms & Conditions as well as the Rules & Regulations set forth by the Arizona Corporation Commission
Please verify that you are human
*
Rows
Amount
Establishment Fee
Guarantee Deposit
Sales Tax
Total Due
Payment Date
Method
Submit
Should be Empty: