Membership Application

Member Database & District Code Set-up Form

Applicant First Name*:
Applicant Last Name*:
Applicant Email*:
Company Name
District Code Name
10-Digit Ticket Check Code
Buried Facility/Utility Service Area (check all that apply)
    
Types of Underground Facilities (check all that apply)
Tickets Transmitted Via:
Ticket Check Positive Response Method:

DAYTIME - District Code Contact Information

If you are using a contract locating company, their information should be entered below.
Daytime Contact Name
Daytime Phone No.
Daytime Fax No.
Daytime E-mail Address (if available)
Alternate Contact Name
Alternate Phone No.

Hours of Operation

AFTER HOURS - District Code Contact Information

We will voice out Emergency Ticket(s) only when your office is closed. If you are using a contract locating company, their information should be entered below.
Primary - After Hours Contact Name
Primary - Emergency Phone
Secondary - After Hours Contact Name
Secondary - Emergency Phone
Please document any special after hour notification requirements:

MEMBER - Contact Information

This is the person who will receive invoices.
Billing Contact Name
Billing Phone No.
Billing Fax No.
Billing E-mail Address (if available)
Mailing Address

Membership Contact Information

This is the person who will receive monthly subscriber minutes from various Call Center Meetings.
Membership Contact Name
Contact Phone No.
Contact Fax No.
Contact E-mail Address (if available)
Mailing Address

MEMBER Database / Mapping Contact Information

This is the person we will contact for member buried plant and notification matters.
Database / Mapping Contact Name
Contact Phone No.
Contact Fax
Contact E-mail Address (if available)
Mailing Address
The below contact information will be posted on the Miss Utility web site.
Customer Service Phone No.
Damage / Repair Phone No.
Marking Concerns
Comments or Special Instructions