Customer Name(Required) First Last Customer Information(Required) Owner Renter Landlord Property Manager Service Address(Required) Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address Same as previous Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Location on Property(Required) SUB Account Number(Required) Email(Required) Home Phone(Required)Cell PhoneDate(Required) MM slash DD slash YYYY MessageCustomer Consent(Required) I hereby verify the information to be true and complete. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.By hitting submit, I: *Certify that all information I have provided is true and accurate. *Authorize SUB to provide my contact information to the program contracted tester. *Grant SUB permission to schedule and authorize a certified backflow tester to enter the property listed above to test the backflow prevention assembly. *Agree to provide access for the purpose of testing the backflow assembly. *Choose to voluntarily enter into SUB’s backflow assembly testing program *Agree to pay a $29.00 per assembly testing fee that will be included on my SUB statement upon completion of assembly testing. *Understand that any backflow assembly repair or replacement will need to be scheduled by me and are separate costs that are not included in the testing fee. *Understand that I will remain on the program until either, I contact SUB to remove myself or I move. *Understand that SUB has the right to remove me from the program at their discretionCustomer Electronic Signature (Type Your Full Name)(Required) CAPTCHA