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2. Name of Company*
3. Phone Number*
5. Address*
6. City*
8. State*
9. Zip*
10. Is this the billing address? *

    1. Yes
    2. No
12. Billing Address
14. Billing City
15. Billing State
16. Billing Zip
18. Bank Name*
19. Bank Address*
21. Deposit
22. When would you like service to start?*
    When would you like service to start?

    When would you like service to start?
24. Deposit
    Deposit
25. Quantity
26. Shipping Cost
27. Taxable
29. A nonrefundable convenience fee for all online transactions will be added upon checkout.
31. Check Here*

    1. I agree my electronic submission of this form constitutes my signature affirming the above information is true and correct.
33. Signature*
34. Date*
    Date
36. IF WATER SERVICE IS OFF: The Town of Firestone will require account balances be paid in full. The customer requesting water to be reinstated will need pay a reconnection fee and set an appointment one business day in advance to have water service reinstated. Cut off time is 4:30 p.m. daily for requesting reinstatement for the next business day. All appointments will require someone to be present at the property when the water is reinstated. Please contact town hall at 303-833-3291 to inquire about the status of the property entered above.
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37. Calculate Totals Proceed to Checkout

* indicates a required field