Order Form

Choose your options:

  bottle a month at $11.00/bottle  
+ cooler a month at $12.00/cooler is $23.00/month
    ×  month
    Sub-Total:   $184.00
    Sales Tax: + $15.64
    Total:   $199.64

Please provide us with a first name

Please provide us with a last name

Name:


First


Last


Please provide us with a building name

Please provide us with a room number

Dorm:


Building


Room Number


Please provide us with a valid phone number

Please provide us with a valid email address

Phone:


Phone Number


Email:


Email Address



Please choose a method of payment

Please provide us with a name for your credit card

Please provide us with a valid credit card number

Please provide us with a valid Credit Validation Code (CVC)

Method of Payment:



Name on the Card


Expiration Month


Expiration Year



Card Number


CVC (?)

Visa

Unfortunately, we cannot accept check payments online. Your order will still be recorded and a Wydown Water representative will contact with you within the first week of classes to arrange payment.
Unfortunately, we cannot accept cash payments online. Your order will still be recorded and a Wydown Water representative will contact with you within the first week of classes to arrange payment.

Please review your order information below and click the order button below to confirm your order.

   bottles per month
+  coolers per month
×  months
Total: $.00
Name:   Dorm:  
Email: Phone Number:
Method of Payment:    
Name on Card: Card Number:
Expiration Date: / CVC: