ACWA Membership Application

Please complete the application below and send 
with Check or Money Order to:
Ruby Poteet
8303 Middle Wa rren Road
Pine Bluff , AR   71603

 
Name: _____________________________________________________________

Company or Ranch: _________________________________________________

Address:____________________________________________________________

City/State/ZIP: _____________________________________________________

County:_____________________________________________________________

Telephone:__________________________________________________________

Fax:________________________________________________________________

E-mail:_____________________________________________________________

I was encouraged to sign up by:___________________________________
 

 
Please Complete:
 ACWA New      ACWA Renewal  ANCWA New      ANCWA Renewal  

Type of Membership:
 ACWA $10
ANCWA $50

 
Check one:      Check      Money Order