ARKANSAS LIHWAP
Interest Form

For more information about this program click here:

This form is ONLY for Water and Wastewater systems providing residential services in the State of Arkansas.

**FOR INDIVIDUALS**

www.arkansaslihwap.com

Company Information

Name of Water/Wastewater system/Billing System (Company Name)

Please enter your company name.

Water/Wastewater/Billing System (Company Type)

Primary Point of Contact Information

Point of Contact - First Name

Please enter the Company Point of Contact's First Name.

Point of Contact - Last Name

Please enter the Company Point of Contact's Last Name.

Point of Contact - Position Title

Please enter the Company Point of Contact's Position Title.

Point of Contact - Phone Number

Please enter the Primary Point of Contact Direct Phone Number.

Point of Contact - Email

Please enter the email address where the Company Point of Contact can be reached regarding enrollment in the AR LIHWAP Program.

Point of Contact - Email Confirmation

Please re-enter the email address where the Company Point of Contact can be reached regarding enrollment in the AR LIHWAP Program

Third Party Billing Information

Are you a Water and/or Wastewater System using a third party billing company?

If yes, please complete as much of the Billing Company information as possible.

Send me a copy of my responses

Company Information