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2. CITY OF MIDLAND 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 Application
   Date of Application
6. First Name*
8. Last Name*
10. Date of Birth*
    Date of Birth
12. New Service Address*
14. Renting or Buying?*
    -- Select One --RentingBuying
16. Prior Service In Midland?*
    -- Select One --YesNo
18. Prior Service Address
22. Employer's Name*
24. Employer's Address*
26. Employer's Phone*
28. Spouse's Employer
30. Spouse's Employer Address
32. Spouse's Employer Phone
34. Address where bills are sent*
36. Contact Phone*
38. Date to be turned on*
    Date to be turned on
40. Driver's License #*
41. License Issuer*
    Insert the Issuer of your License such as State, Province, Country, or other issuer not listed.
43. Email Address*
45. Do you want your "Personal Information" kept confidential?*
    -- Select One --YesNo
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

* indicates a required field