Schedule a Hookup - Mid-Dakota Rural Water

Schedule Hookup

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Customer Information

First Name (required)

Last Name (required)

Organization

Mailing Address 1 (required)

Mailing Address 2 (required)

City (required)

State (required)

ZIP (required)

Example: #####

Phone (required)

Example: (###)###-####

Cell Phone (required)

Example: (###)###-####

Email (required)

Example: janedoe@fakeemail.com

Hookup Information

What do you want to do (required)

Discuss a new hookup

Transfer an existing hookup to a new person

Disconnect an existing hookup

Describe Location Of Hookup

(e.g., Account or location number (if existing) Township – Range- Section - Quarter, Physical address, cross roads, landmarks, distances) Timeframes Describe use of hookup (e.g., Residential only, Farmstead with outbuildings and/or livestock, bulk water, commercial, ag commercial)

Hookup Description (required)

Timeframe

When would you like this to be completed?

Suggested timeframe (required)

Purpose

(Residential, Farmstead (with outbuildings), Commercial, Livestock etc...?)

Hookup Purpose (required)

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