Water Quality Report Request Form

1

Please check the box below to receive a paper copy of the Water Quality Report.

I would like the City of Fort Lauderdale to mail me a paper copy of the annual Water Quality Report.

2

Fort Lauderdale Utility Billing Account Number (if applicable)

Fort Lauderdale Utility Billing Account Number (if applicable)

3

First Name

 *

First Name

4

Last Name

 *

Last Name

5

Mailing Address

 *

Mailing Address

6

Apt

Apt

7

City

 *

City

8

State

 *

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

9

Zip

 *

Zip

10

Phone

Phoneext.

11

Email

Email

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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