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2. Please complete the online form below to submit your request.
   The Town's Utility Billing Department will contact you with your access number as soon as possible. If you need water immediately, please visit our Water Billing Office located at 645 Beacon Lite Road.
4. Have you ever had a Bulk Water Account with the Town?*

   1. YES
   2. NO
8. First Name*
9. Last Name*
11. Mailing Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Email Address
19. Date Service to Begin*
    Date Service to Begin
23. PLEASE READ THIS AGREEMENT AND TYPE YOUR NAME BELOW:

    The undersigned hereby requests the Town of Monument to furnish water service to the person designated herein. In exchange for these services, the undersigned agrees to be responsible for all charges for bulk water, until such time as the undersigned gives proper notification to the Department of Water that the services are to be discontinued. In the event the undersigned fails to make a particular payment for water service, the Town of Monument shall immediately become entitled to exercise any and all creditor remedies for collection of amounts owing, which are allowed by law. The undersigned agrees to pay all costs and attorney’s fees incurred by the Town of Monument in collection of any amount due.

    
    

    Bulk water is billed once per month and due by the 20th of the following month. A $12.50 late fee will be charged for payments not received by the 20th of the month. There is a $25.00 insufficient fund charge. A $20.00 shut off fee is applied to account IF notice is posted. Your account will be blocked and a shut off charge will be added to your account as follows: $50.00 for the first offense, $100.00 for the second, and $150.00 thereafter.

25. The undersigned hereby requests the Town of Monument to furnish water service to the person designated herein. *
    BULK WATER STATION ADDRESS: 538 W. HWY 105
27. Please create a 4-digit pin #*
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

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