Fill in the form below to submit your application. Download a copy here if you’d prefer to print the application and submit it by mail. Please contact the WIWSA treasurer with any questions.

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Application Type (Select One)

• New Application for Membership
• Membership Renewal
• Updating Membership Information

Water System Name *

Number of Active Connections *

Designated Representative *

First

Last

Mailing Address (Street or PO Box, Town, City & Zip Code) *

Phone Number *

Email *

Alternate Representative

First

Last

Email

Backup Contact (optional), Name and Email Address

Backup Contact (optional), Name and Email Address

Dues (Select One) *

• Group A system, $2/connection up to a max of $200
• $25 – Private Well Owner with 1 active connection
• $25 – Group B System with 2-14 active connections
• $25 – Associate membership
• Updating Contact Information only

Submitted by: *

First

Last

Title *

Submit Application