New Customer Application - Midway-Canaan Community Water Association

Application for Utility Service

This checklist is provided to help you put together the information needed to set up your utility account.

Completed City Utility Service Application
State or Federal Current Issue Photo ID for ALL applicants
Deposit and Application fee in the form of check, money order, or credit/debit card (Visa/MC) -$75.00 deposit and $25.00 Fee
Proof of Social Security Number for ALL applicants

Proof of Residency:

FOR RENTERS: A copy of your signed lease
FOR OWNERS: Intent to Purchase, Settlement Statement, Deed

Account Name

Today's Date

mm/dd/yyyy

Service Address

Mailing Address

Account Type

Residential
Commercial

Turn On Date

mm/dd/yyyy

Name

First

Last

Driver's License#

Driver's License State

Social Security#

Home Phone Number

Cell Phone Number

Work Phone Number

I agree to abide by all provisions and applicable rules of the association in regard to It’ s service of the utility system and agree to pay for such services in accordance with rates and regulations in effect at the time of delivery. Transferring an account to a different address requires that all payments at my current address are paid. I also understand that services can be disconnected under rules and regulations in effect concerning non-payment of account.

Agree

Customer Signature

Today's Date

mm/dd/yyyy