Membership Type*MEMBERSHIP TYPE: (Reminder: VOTING members are towns, municipalities, schools, etc. and ASSOCIATE members are companies.) Voting Associate PWSID* County:* Functions* Water Wastewater Both Water Source* Ground Surface Other Please select your population served*1 - 50 ($100.00)51 - 150 ($150.00)151 – 1,500 ($250.00)1,501 – 3,000 ($300.00)3,001 – 6,000 ($350.00)6,001 – 10,000 ($400.00)10,001 – 100,000 ($500.00)100,001 & up ($550.00+))Total Contact InformationOrganization or Company Name* Primary Contact First Name* Primary Contact Last Name* Title Physical Address* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip* Office Phone*Cell PhoneFor publications, please list Office Phone Cell Phone Primary Email* Mailing AddressMailing Conditional Mailing Address is different from Company Address Mailing Address* Mailing City* Mailing State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingMailing Zip* Use this address for listing in the membership directory Billing ContactBilling Conditoinal Billing Address is different from Company Address Billing First Name* Billing Last Name* Billing Title* Billing Phone*Billing Email* Billing Address* Billing City* Billing State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingBilling Zip* Tell Us About Your Company / OrganizationPlease provide a brief description of your products or servicesMembership Consent* By checking this box, I agree to the terms of service and privacy policy.Payment InformationTotal Payment Method*Credit Card American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name