Form Center

2. City of Miss Point and Escatawapa Suburban and Utility District
4. The undersigned applicant(s) makes application for utility services at and upon the premises below and agree to the terms and conditions of the Utility Service Rules and Regulations. A copy of which are hereby acknowledged and received by the undersigned. The applicant(s) do further agree to follow and abide all resolutions, order and ordinances of the City and EUD pertaining and connected in any way to utilities and utility service. The applicant(s) agrees that the following information furnished true and correct:
8. First Name
   (If married, enter name of husband and wife, both must sign. If business, enter the name of the company.)
9. Last Name
11. Address Service is Requested
13. Evidence of Ownership of Interest
15. Mailing Address
17. City
18. State
19. Zip Code
21. Any Previous Service with City of Moss Point or EUD

    1. Yes
    2. No
22. If yes, address
24. Mailing Address
26. City
27. State
28. Zip Code
30. Service Desired (select one)

    1. Residential
    2. Commercial
    3. Industrial
    4. Business

    1. House
    2. Trailer
    3. Apartment
    4. Vacant Lot
32. Home Telephone
33. Business Telephone
35. Name of Employer
37. In Case of Emergency Call:
39. Name
41. Relationship
42. Telephone
44. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
46. Applicant Signature
47. Date
    Date
49. Co-Applicant's Signature
51. Completing Utility Form
    Applicants will have to provide their driver’s license, proof of inspection, social security card, and proof of residency at the Utilities Office to complete the application process.
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field