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2. 
4. Account #:*
5. Property Owner Name*
9. Customer Name*
11. Service Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Email Address*
22. Request of mailing address changed on the account.
24. Current Mailing Address*
26. City*
27. State*
28. Zip Code*
32. New Mailing Address*
34. City*
35. State*
36. Zip Code*
40. I agree to notify BRWU of any further changes to my billing information/mailing address upon return.
42. Shut-off Water
    Shut-off Water
43. Turn-on Water
    Turn-on Water
45. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
47. Electronic Signature*
48. Date*
    Date
50. *Customers will be responsible for service disconnection and reconnection charges. Base monthly facility charges shall continue to accrue to the Customer and the premises.
52. Telephone: 800-826-5721
53. Form 2 – Rev 12/6/18
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field