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Friday, July 30, 2010

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Preferred User Information

Preferred User Information

Preferred User Information

*Note: Membership to this portal is Verified. Once your account information has been submitted, you will receive an email containing your unique Verification Code. The Verification Code will be required the first time you attempt to sign in to the portal environment. All fields marked with a red arrow are required.

Enter a username

User Name:

User name is required

Enter a First Name

First Name:

First name is required

Enter a Last Name

Last Name:

Last name is required

Provide a Display Name

Display Name:

Display Name is required

Enter a valid Email address

Email Address:

Email is required

Enter a password.

Password:
Confirm Password:

Security Code:	Enter the code shown above in the box below

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Primary Contact Information

Enter the Contact Name of the Primary Emergency Contact.

Contact Name :

Enter the telephone number of the Primary Emergency Contact.

Telephone Number :

Enter the alternative telephone number for the primary emergency contact.

Alternative Number :

Enter the email address for the primary emergency contact.

Email :

Enter the fax number of the primary emergency contact.

Fax :

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Secondary Contact Information

Enter the contact name of secondary emergency contact.

Contact Name :

Enter the telephone number for the Secondary Emergency Contact.

Telephone Number :

Enter the email for the Secondary Emergency Contact.

Email :

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Utility Information

Utility Name

Enter the street address of the utility.

Street Address :

Enter the city part of the address

City :

City is required

Enter the name of the county of the utility.

County :

Enter the state of the utility.

State :

Enter the Zip Code of the utility.

Zip :

Enter the 24/7 Operational Phone Number for the Utility.

24/7 Ops Phone :

Water Supply Serial Number

National Pollutant Discharge Elimination System

Signed MAA?

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