WaterDepartment/104E.5
th
Ave/POB
ox928/Emporia,KS66801/6203434244/utilities@emporiakansas.gov
Informationtoenrollinstatementsbyemail:
AccountNumber:_______________________________________
CustomerName:________________________________________
ContactName:__________________________________________
ContactPhoneNumber:_____________ ______________________
EmailAddresstosendstatement:__________________________________________
IherebygivetheCityofEmporiapermissiontoemailacopyofthemonthlystatementtotheabove
statedemailaddress.
Signature_____________________________________________
Date______________________