Services Application — Welcome To Coldwater, MS

Coldwater Water, Sewer, and Trash Services Application

To sign up for utility services, please fill out the fields below. After the form is submitted, you will be contacted with instructions to complete the process. The process to set up a new account may only be completed on a working business day and may take up to 48 hours. If you need services sooner, call 662-622-7241 for instructions.

A $150 deposit is required for all services.

Please fill out all information below.

Name

First Name

Last Name

Driver's License Number

Social Security Number

(###)

###

####

Phone number

(###)

###

####

What services are you interested in?

Water

Sewer

Trash

Service Begin Date

YYYY

Service Address

Mailing Address

If rent, provide homeowner's name and phone number.

Employer's Name and Phone Number

Please Select One

By filling this out, I am requesting the Town of Coldwater (hereinafter called the Town) to supply service at the above mentioned location, and agree to receive and pay for such service(s) rendered in accordance with rates of the Town in effect at the time of service. The applicant agrees to allow the Town and/or its agent entrance onto above mentioned property to read meters, maintain and improve system, and any other activity concerning the operation of the system. The undersigned agrees to follow the Mississippi Department of Health requirements regarding onsite wastewater (website: www.msdh.ms.gov). I acknowledge that I have read and understand the above.