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2. CITY OF MIDLAND COMMERCIAL WATER APPLICATION
   
   
   Fill in the form below to sign up for New Utility Services with the City of Midland. You will receive a reply email whether the application is approved or denied.
   
   
4. Date of This Application*
   Date of This Application
6. Business Name*
8. Care-Of or Attention
10. New Utility Service Address*
12. Bill Mailing Address*
14. Contact Phone*
16. Prior Service In Midland?*
    -- Select One --YesNo
18. Prior Service Address
20. The section below is contact information of the person coming to the office to sign the application form.
22. Primary Contact Name*
24. Date of Birth*
    Date of Birth
26. Primary Contact Phone*
28. Primary Contact Email Address*
30. Primary Contact Driver's License #*
31. License Issuer*
    Insert the Issuer of your License such as State, Province, Country, or other issuer not listed.
33. Date to be turned on*
    Date to be turned on
35. Do you want your "Personal Information" kept confidential?*
    -- Select One --YesNo
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field