K.W.R.S. Online Bill Pay-Additional Information
**Please use the following form to record your response when submitting an online bill pay
Customer Details:
Question 1-Full Name
*
First Name
Last Name
Question 2- Email
*
example@example.com
Question 3- Service Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Question 4- Type of Can
*
Customer Provided Can
Company Provided Can
Question 5 - Payment Information:
*
***Please enter Invoice Number (or other info.)for proper credit to your account***
Comments / Suggestions (if any):
Submit
Should be Empty: