2. 
4. Ephrata Borough Budget Billing Application.
6. Full Name*
8. Daytime Phone Number*
10. Account Service Address*
12. Click the appropriate box below:*

    1. Owner
    2. Tenant
14. Name and address of owner
16. Name*
    By entering your name and date above, you are signing this form and agreeing to all terms and conditions of this application.
17. Date*
    Date
Leave This Blank:


19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field