Required fields are marked with asterisks (*)

Application for Bulk Water Use

Please select one of the following:

I am a first time customer

I am a returning customer

What is your organization name?

What is your first name?

What is your last name?

What is your mailing address ?

What is your phone number?

What is your email address?

Confirm your email address

Acknowledgment

Please select the following

I/we hereby apply for permission to use the Bulk Water Station at 116 Luxton Way.

I/we understand that a deposit is required prior to use of the Bulk Water Station and any consumption used above the deposit amount will be invoiced to the applicant. Deposit must be replenished once depleted.

I/we understand that the Town of Shelburne may cease the Bulk Water Fill at any time at their discretion.

I/we agree to make fill appointments/arrangements with the Utilities Supervisor and will notify said person to any changes.

Signature of applicant

Clear

Select today's date

Bulk water contract period

Please select start and finish date.

Date start

Date end

Estimated volume per fill?

Fills days per week

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