Jasper Water Form - Owner Date MM slash DD slash YYYY Name(Required) First Last Phone(Required)Billing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Account Number(Required)Location/Meter No.(Required) Description of maintenance and/or meter installation or removal, transfer, etc. performed:(Required) Current Meter Reading:(Required) Consent(Required) AgreedNo deposit is required as I own the property. I agree to notify the Jasper Water Works Corporation at (618) 842-2666 if I sell the property within 10 days and I will provide them with a forwarding address for billing purposes. If legal action is required regarding any unpaid outstanding balance, I agree to pay any and all costs for such action. I have received a copy of the rules, rates and regulations of Jasper Water Works Corporation.Applicant Electronic Signature (Full Name)(Required)
