City of Mineral Wells ♦ 211 SW 1st Avenue ♦ Mineral Wells, TX 76067
Phone Number (940) 328-7720 ♦ Fax Number (940) 328-7732
waterbilling@mineralwellstx.gov
WATER SERVICE APPLICATION
Spouse/Next of Kin: _________________________________________________________________________________ Gender
Home Phone: ____________________________ Work Phone: _________________________
Do you rent ( ) or own ( ) Landlord’s Name: _____________________________________ Phone: _____________________
Service Address: ___________________________________________________________________________________________
Mailing Address: ______________________________
______________________________________________________________
Water Deposit Amount: $150.00
Commercial
Date to Open Account:
Name of Company or Business: __________________________________________________________
______________________
Legal Representative: ________________________________________________________________________________________
Social Security# (last 4 digits): _____________ Driver’s License or ID: _______________________________ State: _______
Federal Tax Id#: ____________________________________ Phone Number: _________________________________________
Service Address: ____________________________________________________________________________________________
Mailing Address: ____________________________________________________________________________________________
I ACKNOWLEDGE THAT MY PRESENCE IS REQUIRED FOR CONNECTION OF SERVICE. IF CONNECTION OF SERVICE IS
NOT POSSIBLE DUE TO RUNNING WATER, YOU MUST RESCHEDULE CONNECTION AND A $25.00 SERVICE CALL FEE
WILL APPLY. PLEASE COMPLETE ALL FIELDS POSSIBLE TO AVOID DELAYS IN WATER SERVICE ACTIVATION.
_______________________________________________________
Applicant Signature
Date
Do you wish your personal information to be confidential? Yes
No
I am at least 60 years of age and request the Late Penalty Exemption.
Residential Account Name Change Only
Date to Open Account: _____________________________________
Name: __________________________________________________________________________________
Social Security# (last 4 digits): _____________ Driver’s License or ID: _______________________________ State: _______
Date of Birth: _______________ Home Phone: ___________________________ Work Phone: __________________________
Email: __________________________________________________________________________________________
OFFICE USE ONLY
Account#:
Input By:
Deposit Amount/Receipt#:
C/O Paid: Yes No
C/O Approved:
Lease or Proof of Ownership:
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signature
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