Roosevelt Water Association           

P.O. Box 345;
Snohomish, Washington 98291
(360) 568.3450 Fax (360) 563.5369 Email

Membership Information Form

Account Number if you know it:

Service Address:

Billing Information
First Names: Last name:

Are you the Owner Renter

Billing Address:

Billing City: Billing State: Billing Zip Code:

Phone Number Home:
Phone Number Home:
Work Number:
Cell Number:

Email Address:
Email Address:
Email Address:

Owner Information If you are the renter
Owner First Names: Owner Last name:

Owner Address:

Owner City: Owner State: Owner Zip Code:

Phone Number Home:
Cell Number:

Email Address:

Backflow devices
Please check all that you have.

Swimming Pool Jacuzzi Hot Tub Underground Sprinkler System Drip Irrigation Sysstem Green House Solar Panels
Swamp Cooler Fire Sprinkler System Utility Sink with threaded faucet Ghost Pipes (unidenitifiable piping)


Now please press Submit.