*1.Are you a member of Connecticut Rural Water & Wastewater Association (formerly known as Atlantic States Rural Water and Wastewater Association)?(Required.)

Yes

No

Not Sure

*2.Name of Utility(Required.)

*3.# of population served(Required.)

*4.Contact Name(Required.)

*5.email address(Required.)

*6.Street address #1(Required.)

*7.Street address #2(Required.)

*8.City(Required.)

*9.State(Required.)

*10.Zipcode(Required.)

*11.Phone Number(Required.)

*12.Do you give CTRWWA permission to send you newsletters, emails, and other communications?(Required.)

Yes

No