Residential Application

Co-applicant

First NameMiddle NameLast Name
Date to Connect (Normal Bus. Day)*

MonthDayYear
Date
Service Address*
OwnRent/ Lease
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PhoneTextEmail
Provide Cellphone Provider
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
* The City of Melissa does require a deposit of $150.00 when making your request to establish services

* The City of Melissa service request, requested before 2:00pm Mon-Thurs and 10:00am on Friday. Any request made after said times will be the next business day.

* The 95 gallon Trash and 95 gallon Recycle cart will be provided and delivered to your residence. Existing homes already have carts.

* PLEASE BE ADVISED: If you have purchased or rented a home with an
automatic irrigation system (sprinkler system), the system's settings likely have
been set by the homebuilder or the previous s occupant. Please take the time
to check the settings and adjust them to your own watering preference, as you will be responsible for all water charges accrued after your utility service is connected.
Signature*

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