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2. Email Backflow Reminder Notice
4. Name*
6. Email Address*
8. Address*
10. City
11. State
12. Zip Code
14. Phone Number*
15. Fax Number

17. The city shall not be responsible for any undelivered emails. If the email address changes, it will be the responsibility of the customer to notify the backflow coordinator, they can be reached at   253-851-6157 Monday through Friday 7:30am - 3:30pm. Email reminders will only be sent before the test due date. Any further notifications will be sent by standard mail.

19. Terms of Argeement*

    1. By clicking this box, I agree to the terms and conditions as set out in this application and in the City of Gig Harbor Municipal Code.
21. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
23. Electronic Signature*
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field