Transfer Service

Residential Transfer Service Request

Account Holder

Account Number

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

Relation to Applicant

Employer

Current Address

Do You Rent or Own?

Life Support Equipment At Current Address?

Street Number

Street Name

Apartment Number

City

State

Zip Code

New Address

Do You Rent or Own?

Street Number

Street Name

Apartment Number

City

State

Zip Code

Transfer Services

Select services:

Electric

Gas

Water

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

Life Support Equipment At New Address?

Service End Date

Transfer Service Date

Note: Transfer 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.

Mailing Address

I have a different billing address.

Street Number

Steet Name

Apartment Number

City

State

Zip Code

Submit

Phone Number (10 Digits)

Ext

Email ex: you@gmail.com

Comments(16 chars max)

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Summary

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

Electricity:	{{Service1\|No electricity selected}}
Gas:	{{Service2\|No gas selected}}
Water:	{{Service3\|No water selected}}
Plus1:	{{NewPlus1\|No Plus1 donation selected}}
Life Support	{{LifeSupport\|No life support equipment}}

MLGW Residential Transfer Service Request

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