CCR Order Form

CONSUMER CONFIDENCE REPORT

Name:			Company:
Address:			Phone:
City:			Fax:
State:		Zip:	Email:
			PWS#

	Form of Payment:
	Check (Print form and mail with payment)		#________
	Purchase Order		#________
	Credit Card		We will call you for your number.

Payment is due upon completion of report.

Initial CCR (First Year Production)	$350.00
Newsletter Format (Two sided) Second and subsequent years	$250.00
Brouchure Format (Two sided) Second and subsequent years	$250.00
Copies	$.85 ea