Registration form | Palatine Hill Water District

To receive emergency text alerts as well as information regarding our future online bill pay option, please complete the following form.

Primary contact name*
First Last
Landline phone number (optional)
Primary contact email (for email alerts)*
Enter Email Confirm Email
Primary contact mobile number (for text alerts)*
Street address (where water service is provided)*
Street Address City State ZIP Code
Billing address (if different from service address)
Street Address City State ZIP Code
Do you have a pool on site?*
- Yes
- No
Do you have an irrigation system?*
- Yes
- No
How many people reside at your service address?*
Please enter a number from 1 to 10.
Second contact name
First Last
Second contact mobile number (for text alerts)
Third contact name
First Last
Third contact mobile number (for text alerts)
Comments
This field is for validation purposes and should be left unchanged.