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Residential Water Application

2. CITY OF MIDLAND WATER APPLICATION
   <br><br> 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. <br><br>

   
   
   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