Personal Information (water user) |
| Water Service Address |
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| Person(s) who will reside at this account |
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| Additional adults residing at this account |
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| Current Mailing Address (Street/P.O. Box) |
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| City |
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| State |
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| Zip |
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| Home Phone |
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| Cell Phone |
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| E-mail Address |
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| Employer |
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| City |
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| Work Phone |
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| Previous Water Utility |
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Property Owner
(complete only if different than water user) |
| Owner/Member |
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Mailing Address
(Street/P.O. Box) |
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| City |
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| State |
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| Zip |
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| Home Telephone |
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| Work Telephone |
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| Note: It is the Member's responsibility to see that all charges due to PWA are paid in full. A tenant can not be a Member. Only property owners may be a Member of Powshiek Water Association. |
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Iowa Sales Tax Information |
| Average # Persons using water in: |
| Family Household |
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| Summer/Vacation Site |
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| Business |
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| type of business |
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| Church |
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| Government |
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| tax exemption # |
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Agricultural Usage |
| Average # Livestock using Water |
| beef cattle |
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| dairy cattle |
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| pork |
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| sheep |
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| fowl |
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| horses |
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| # gallons for spraying/irrigatin |
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| # gallons
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for
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Check here if you have a medical condition or business that we need to know about. Example: dialysis machine, restaurant, beauty shop? Make certain to provide phone numbers that we could notify about a planned outage.
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| The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in the program. You are not required to furnish the information in this box, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname. |
| Ethnicity: |
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| Race (check one or more): |
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White |
Black or African American |
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Asian |
American Indian/Alaska Native |
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Native Hawaiian or other Pacific Islander |
| Gender: |
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Office Use Only
Tenant / Owner Transfer Date ______________
Billing Supplies Counter / Mailed __________
W/O to Read __________ Final Reading ________000
Previous Customer _____________________________
Last pay date for Previous Customer ________________
First pay date for New Customer ____________________
Poweshiek Water Association
125 Industrial Dr. PO Box 504
Brooklyn IA 52211-0504
5227416 or 800-543-7419
Fax 641-522-7556
pwacustomer@poweshiekwater.com
PWA is an Equal Opportunity provider & employer
In accordance with Federal law and U.S. Department of Agriculture policy, PWA is prohibited from discriminating on the basis of color, race, national origin, sex, religion, age, disability, or marital status.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call (202)720-5964 (voice and TDD).
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