Membership Application

 

Utility Mutual Aid Agreement and Contact Information

The Information provided in the application will be included on the WV WARN secure web site in the password protected "members" area.

* = required field
 

 Utility Profile

Utility Name*  
Membership Type*
 Public Water System Number  
Wastewater Permit Number  
State ID*
Water Connections
Water Population
 

Utility Phone and Address

Phone* ( ext:
Address Line 1*
Address Line 2 
Address Line 3 
City*
State*
Zip*
County*
 

Primary authorized emergency contact

 
First Name*
Last Name*
Title
Day Phone* ( - ext:   
Night Phone* ( - ext:   
Cell Phone ( -
FAX:* ( -
Fallback County EOC emergency number*
Numeric Pager:  
Alpha Pager:  
Email*  
     

Secondary authorized emergency contact

 
First Name  
Last Name  
Title  
Day Phone ( - ext:   
Night Phone ( - ext:   
Cell Phone ( ) -  
FAX: ( ) -  
Numeric Pager:  
Alpha Pager:  
Email  
     

Password

 
Desired Password*
Confirm Password*

Now therefore, inconsideration of the covenants and obligations set fourth in this Agreement, the Water and Wasterwater Utility listed here manifests its intent to be a Member of the Intrastate Mutual Aidand Assistance Program for Water and Wastewater Utilities by executing this Agreement on this Day.