Account Authorization

2. Account Number*

4. Owner Name*

6. Billing Address*

8. Service Address*

10. Owner Phone

11. Owner E-Mail

13. I would like to receive an invoice via

    1. E-MAIL

    1. MAIL

    1. BOTH

17. Authorization

    I give ACWWA authorization to provide the Person/Company listed below the following item(s) concerning my account (Check all that apply)

    1. Balance and Charges

    1. Online Access

    1. Mail Invoice (Duplicate bill fee)

    1. Email "E-Invoice" (No fee)
19. Name / Company

20. Relationship

22. Address

24. Phone

25. E-Mail

29. Remove Previously Authorized Party

    Please include the name of the person or company to be removed from the property listed above.

33. Acknowledgment*

    By Checking the box you acknowledge you are authorized to make changes to this account. The owner of the property remains ultimately liable for such charges stated in SECTION 6.4.4 of ACWWA's Rules and Regulations.

    1. I Accept
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field