Water Hauler Contact Registration

Organization Information

Affiliation (Parent Company):

Operator Name:

NM-DOT (formerly PRC) Case Number:

US-DOT Number:

Secretary Of State Registration: *

I am in good standing and registered with the Office of the Secretary of State

I am a general partnership or sole proprietor and not required to register with the Office of the Secretary of State

* If required to register with the Office of the Secretary of State, then the Operator Name (above) must match exactly or this registration will be rejected.

Description: **

** Please enter a brief description for your water hauler organization or expected duties.
If you already have an OGRID and trying to add additional authorization(s), please mention this in the description.

Address:

City:

State:

Zip:

Country:

Main Phone:

Main Fax:

Central Contact Information

First Name:	* Required
Middle Name:
Last Name:	* Required
Title:	* Required
Phone:
Cell:
Fax:
Email:	* Required* Invalid Email Address

District Contact Information

Please select the district(s) where your wells will be located and enter the Emergency Contact Information

Districts

District 1 - Hobbs

First Name:	* Required
Middle Name:
Last Name:	* Required
Title:	* Required
Phone:
Cell:
Fax:
Email:	* Required * Invalid Email Address

District 2 - Artesia

First Name:	* Required
Middle Name:
Last Name:	* Required
Title:	* Required
Phone:
Cell:
Fax:
Email:	* Required * Invalid Email Address

District 3 - Aztec

First Name:	* Required
Middle Name:
Last Name:	* Required
Title:	* Required
Phone:
Cell:
Fax:
Email:	* Required * Invalid Email Address

District 4 - Santa Fe

First Name:	* Required
Middle Name:
Last Name:	* Required
Title:	* Required
Phone:
Cell:
Fax:
Email:	* Required * Invalid Email Address

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Water Hauler Contact Registration

Districts

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