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2. Application for Bulk Water Customer

   City of Beach

   153 E. Main St., PO Box 278

   Beach, ND58621

   cityofbeach@midstate.net 

   
   

4. Name:*
6. Cell #*
7. Email address:
9. Names of persons authorized to access account information.

   
   

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   Account # or PIN # will only be provided to individuals on the list above.

11. Name*

    of person filling this form

12. Authorization*

    1. Checkbox

    Check for your authorization to create a bulk water account

13. Date*
    Date
Leave This Blank:


15. 1. Receive an email copy of this form.
16. Email address

    This field is not part of the form submission.

17. Submit

* indicates a required field