TAUD Utility Membership Form
Membership Form for Water, Wastewater and Gas Utilities
Name of Utility:
Contact Name:
Mailing Address:
Mailing City:
Mailing Zip: Code
Shipping Address is the same as Mailing Address
Shipping Address:
Shipping City:
Shipping Zip Code:
State:
Phone Number:
xxx-xxx-xxxx
Fax Number:
xxx-xxx-xxxx
E-mail Address:
Web Site:
www.
Services:
Water
Distribution/Collection
Wastewater
Gas
Utility Type:
Utility District
Municipal
Other
County:
Number of Customers:
x $.41 = $
Amount Due
(Minimum $250 and a Maximum of $6,000)
Number of customers should include the total number of taps for both
water
and
wastewater
.
Pay By Credit Card
Pay Later
Credit Card Information
First Name:
As it appears on card
Last Name:
As it appears on card
Billing Address:
Billing City:
Billing State:
Billing Zip Code:
Card Type:
Visa
Discover
American Express
Mastercard
Card Number:
Enter number without spaces
Expiration Date:
mm/yy
Amount of Payment:
$
Do you want a receipt?
Yes
No
E-mail Address: