Start Service

Residential Start Service Request

Primary Applicant

First Name

Middle Name

Last Name

ID (State)

ID# (License/State)

SSN

Date of Birth

Marital Status

Employer

Co-Applicant

I will need a Co-Applicant.

First Name

Middle Name

Last Name

Maiden Name

ID (State)

ID# (License/State)

SSN

Date of Birth

Relationship to Applicant

Employer

New Address

Do You Rent or Own?

Street Number

Street Name

Apartment Number

City

State

Zip Code

Mailing Address

I have a different mailing address.

Street Number

Steet Name

Apartment Number

City

State

Zip Code

Start Services

Select services:

Electric

Gas

Water

Would you like to contribute $1.00 a month to Plus1?

Life Support Equipment At New Address?

Start Service Date

Note: Start Service requests are normally completed Monday-Friday, 8:00 a.m.- 4:00 p.m. (Excluding Holidays). If your new service request needs to be completed within 2 business days, please do not submit this application and call 901-820-7878.

MLGW does not provide water to Collierville, Bartlett or Germantown.

Previous Address

Street Number

Street Name

Apartment Number

City

State

Zip Code

Submit

Phone Number (10 Digits)

Ext

Email (ex:you@yahoo.com)

Comments(160 chars max)

Summary

{{fname|Anonymous}}, you requested the following:

Electricity:	{{Service1\|No electricity selected}}
Gas:	{{Service2\|No gas selected}}
Water:	{{Service3\|No water selected}}
Plus1:	{{Plus1\|No Plus1 donation selected}}
Life Support	{{LifeSupport\|No life support equipment}}

MLGW Residential Start Service Request

{{fname|Anonymous}}, you requested the following: