2. Prior to completing this application, please read the City of Durango Bulk Water Filling Station User Terms and Conditions
4. Applicant Name*
6. Company Name (if applicable)
8. Address*
10. City*
11. State*
12. Zip*
14. Telephone*
15. Cell*
16. Fax
20. Billing Information
22. Contact*
23. Phone Number*
25. Billing Address*
27. City*
28. State*
29. Zip*
31. Email Address*
35. Vehicle
37. Description (Make/Model/Type of Hauler)
39. License Plate #
40. Capacity (gal)
44. Purpose of Water Use
46. Check all that apply*

    1. Residential Use
    2. Commercial Use
    3. Other
48. By execution, signer certifies that he/she has read the City of Durango Bulk Water Filling Station User Terms and Conditions. In exchange for permission to operate and obtain water from the City’s bulk water filling station, the Applicant/Customer agrees to defend, indemnify, and hold harmless the City and its officers, directors, employees, and agents from and against all claims, costs, losses, and damages, including, but not limited to attorney and other professional fees arising out of, connected with, or resulting from, the connection to the bulk water filling station, and the use of the water therefrom covered by this authorization.
52. Applicant Signature*
53. Electronic Signature*

    1. Check Box
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field