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2. First Name*
3. Last Name*
5. Mailing Address*
6. Well Address (if different from mailing)
8. City*
9. State*
10. Zip Code*
12. Phone Number (Evening)*
13. Email Address*
17. Municipality*
    -- Select One --BrillionBrothertownCharlestownHarrisonNew HolsteinPotterRantoulStockbridgeWoodvilleCity of Chilton
19. By registering, you understand that this is a self sample program. The sample must be drawn on and returned on Monday, August 17*
    -- Select One --Yes, I Understand that I will need to collect samples on Monday, August 17
20. Please select Test Kit preference*

    1. Homeowner's Package - $78
    2. Homeowner's + Metals - $153
    3. Homeowner's + DACT Pesticide Screen - $123
    4. Homeowner's + Metals + DACT - $191

    HOMEOWNER'S PACKAGE: includes Bacteria, Nitrate, pH, Alkalinity, Hardness, Chloride, Conductivity, Corrosivity Index ... METALS PACKAGE: includes 11 metals, including an arsenic screen...... DACT SCREEN: tests for Atrazine and its byproducts

21. Payment Collected on Monday, August 17*
    -- Select One --I will make a check out to Calumet County

    No payments will be collected prior to the sample day, Monday, August 17. Checks Only made out to Calumet County

23. Kit Distribution (Pick up Test Kits)*

    Indicate when you will most likely pick up your test kit.

    1. 5PM - 6:30PM, Monday, August 10 at New Holstein Town Hall
    2. 11AM - 1PM, Wednesday, August 12 at Calumet County Courthouse, Room 105A
    3. 5PM - 6:30PM, Wednesday August 12 at Chilton Town Hall
    4. 5PM - 6:30PM, Thursday, August 13 at Potter Village Hall
24. Sample Return (Sample must be Drawn on August 17)*

    Indicate the location and time you most likely will return the full test kits. Samples must be drawn on Monday, August 17

    1. 11AM - 1PM Monday, August 17 at Calumet County Courthouse, Room 105A (next to Treasurer's Office)
    2. 5PM - 6:30PM Monday, August 17 at New Holstein Town Hall
    3. 5PM - 6:30PM Monday, August 17 at Potter Village Hall
    4. 5PM - 6:30PM Monday, August 17 at Chilton Town Hall
26. Thank you for your registration. Any questions please contact Dani Santry at danielle.santry@calumetcounty.org or 920.849.1442
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

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