HIGHLAND DITCH COMPANY

4309 STATE HWY 66

LONGMONT, CO 80504

Tenant Information needs to be received prior to running water!

STOCKHOLDER(S) INFORMATION        Account No. ____________

NAME:_________________________________________________________________

ADDRESS:______________________________________________________________

CITY: ________________________ STATE: _________________ ZIP______________

PHONE NUMBERS:

            DAY: ______________________________________________

            NIGHT: _____________________________________________

TENANT(S) INFORMATION

Below list person(s) who you are authorizing, as the shareholder, to order water from your account for 2011.

NAME: __________________________________ PHONE NO. ___________________

NAME: __________________________________ PHONE NO. ___________________

 Are the above tenant(s) allowed to move water in and out of your Highland Ditch Company account or system?  

_____ YES

_____ NO

*________________________________________ DATE: _______________________

Shareholder(s) Signature / if Entity state your position