Connecticut Onsite Wastewater Recycling Association

Connecticut Onsite Wastewater Recycling Association P.O. Box 116, East Hampton, CT. 06424 Phone/Fax: 860-267-1057 Cell: 860-638-8188 E-mail: [email protected] On the web at www.cowra-online.org 2016 Membership Invoice and Application Annual Dues are $100 for the initial member and $75 for each additional member within the company. Make check payable to COWRA. Please note: Member dues must be received by February 15, 2016 to guarantee that your company is listed in the 2016 COWRA Member, Consumer and Suppliers Directories.

Name: ______Date: ______

Company Name: ______

Address: ______(Note: The address listed here will be the address listed in the 2016 COWRA Member and Consumer Directory’s. All COWRA mailings will be sent to this address.)

City/State: ______ZIP______

Phone: (____) ______Fax: (____) ______

Email: ______Website:______

Please check: Employee Owner CT State License Number:______

Please check all appropriate boxes so that customers looking for your services will be able to find you in our website directories.

Installer / Pumper Cleaner / Engineer / Health Official ___ Septic System Installer ___ Excavation ___ Pumper / Cleaner ___ Foundations ___ Septic Inspections ___ Drainage ___ Civil Engineering & Design ___ Construction ___ Engineering Services ___ Demolition ___ Health Official ___ Trucking ___ Cameras / Videos ___ Waterproofing ___ Water Jet ___ Paving ___ Supplier ___ Surveying ___ Landscaping ___ Plumbing ___ Drain Cleaning ___ Proprietary Installation ___ Grease Trap Cleaning ___ Sewer Line Installation

Other services not listed ______Normal Work Radius: ______Suppliers ___Concrete Septic Products ___Plastic Septic Products ___ Pumps ___ Portable Toilets ___ Sand, Gravel & Topsoil ___ Chemical Products ___ Proprietary Systems Manufactures ___ Insurance ___ Drainage Products ___ Septic Tanks ___ Filter/Baffles ___ Drip Irrigation Products ___ Water Treatment Systems ___ Grease Stopper Products

Suppliers, please list other product categories. ______

PLEASE NOTE: COWRA USES THIS FORMS INFORMATION TO UPDATE OUR CONSUMER DIRECTORIES. FAILURE TO FILL OUT THIS FORM AND RETURN IT WITH YOUR MEMBERSHIP DUES MAY RESULT IN INCORRECT INFORMATION BEING PROVIDED TO CONSUMERS VIEWING OUR DIRECTORIES FOR OUR MEMBERS SERVICES. OUR DIRECTORIES ARE UPDATED EACH YEAR, ERRORS AND CHANGES ARE NOTED AND UPDATED WITH EACH MEMBERSHIP RENEWAL.