Bulk Fill Station Application

Today's Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Applicant Information

Company Name

Last Name *This question is required.

First Name *This question is required.

Middle Initial

Primary Phone Number *This question is required.

Alternate Phone Number

Email This question requires a valid email address.

Truck Number

Preferred contact method *This question is required.

Are you applying for a single access/pin number or multiple? *This question is required.

Multiple access/pin numbers

Driver Name

Driver's Contact Phone Number

Truck Number *This question is required.

For Business Only

Federal Tax Identification Number This question requires a valid number format.

For Individuals Only

Select and fill in one of the following:

Date of Birth: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Driver's License Number *This question is required.

State ID Number *This question is required. This question requires a valid number format.

Billing Address

Address *This question is required.

Apartment/Unit Number

City *This question is required.

Zip Code *This question is required. This question requires a valid number format.

Is your home/business address different than your billing address? *This question is required.

Home/Business Address

Address *This question is required.

Apartment/Unit Number

City *This question is required.

Zip Code *This question is required. This question requires a valid number format.

Existing Superior Water, Light & Power Customer? *This question is required.

Existing Account Number *This question is required. This question requires a valid number format.

Acknowledgement and Signature

Signature *This question is required.

Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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The above information is true to the best of my knowledge. By signing this, I authorize Superior Water, Light, & Power to start a non-utility account on my behalf and to bill charges accumulated at the Bulk Fill Station. I understand that I am financially responsible for any balance that is remaining on that account. I also understand that I am responsible for notifying Superior Water, Light & Power regarding any changes that need to be made to the above information.