High Priority Customer Self-Identification Form
Customers that require water to maintain the general health of the public
Facility Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Primary Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Facility Type
*
Please Select
Correctional Facility
Daycare Center
Fire/Police Station
Government Facility
Industrial/Manufacturing Facility
Large Commercial Water User
Medical/Dental Office
Pharmacy
School/University
Any other facility WSSC Water defines as a High-Priority Customer
Enter Facility Type
Additional Facilities
Kindly enter the number of additional facilities owned (if applicable)
Additional Comments
Submit
Should be Empty: