2020 System Membership Form

• System Name*
• Please indicate the individual who should receive correspondence. Your assistance in providing the following information will make it easier for the Association staff to meet your system's needs.
• Correspondence*
  Board President/MayorWater/Wastewater Superintendent/ManagerPublic Works DirectorOffice ManagerClerkOther
• Correspondence (Other)
  Please input title in space provided.
• Number of Connections*
  • 1-392 (Min. Membership Dues)
  • 393-2499 (Variable Membership Dues)
  • 2500 Plus (Max. Membership Dues)
• Membership dues in Missouri Rural Water Association are not deductible as charitable contributions for federal income tax purposes. However, they may be deductible as professional or business expenses, to the extent allowable by law.
• Minimum Dues
  Price: $220.00
• Maximum Dues
  Price: $1,400.00
• # of Connections*
  The number of system connections ranges from 393 to 2499.
  Price: $0.56 Quantity:
• # of Connections*
  Please enter/re-enter the exact number of system connections.
• Phone*
• FAX
• Email*
  Enter Email Confirm Email
• Billing Address*
  Street Address Address Line 2 City ZIP Code
• Please read and check accordingly*
  • Billing Address differs from Physical Address
• Physical Address*
  Street Address Address Line 2 City ZIP Code
• Counties service is provided in:
• Board President or Mayor*
  First Last
• Board President/Mayor Address*
  Please check this box if Board President/Mayor receives correspondence at a different address.
  • Board President/Mayor Correspondence Address
• Board President/Mayor Correspondence*
  Street Address Address Line 2 City ZIP Code
• Water Superintendent/Manager*
  First Last
• Certification Level
  (Example: DS-II, DW-C)
• Clerk/Office Manager*
  First Last
• Certification Level (if applicable)
  (Example: DS-II, DW-C)
• Please list all certified operators and their certification levels below.
• DS-Distribution
• DW-Water Treatment
• WW-Wastewater Treatment
• Certified Operators*
  To add names, click the (+) sign to the right of the row.

  First Name	Last Name	Certification Level

• Credit Card
  Note: When paying by credit card, please ensure that Billing Address matches the address associated with credit card.
  American Express

  Discover

  MasterCard

  Visa

  Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date   Security Code Cardholder Name
• To prevent additional charges to your credit card, X out of screen once form has been submitted.
• Total
  $0.00
• Quantity