New AccountAccount Type:(Required) New Residential Account New Commercial Account Account Contact Name(Required) First Last Business Name: (*If Applicable) Physical Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mailing Address (*If Different) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Main Account Phone Number(Required)Cell PhoneEmail(Required) Social Security #(Required) Driver's License #(Required) Check Service Type:(Required) Homeowner (Deed Required) Rental (Rental or Lease Agreement Required) Commercial Industrial Current Place Of Employment:(Required) If You Have Been On Our Services Before, Where And When? Previous Gas / Water Company: Previous Service Address: Notice:Each customer is responsible for monitoring and maintaining any buried gas piping that is downstream of their meter. If this piping is not maintained and periodically checked for leaks or heavy corrosion, an unsafe condition could occur. If an unsafe condition (leak) is found or should happen to occur, it is the customer's responsibility to make repairs immediately. Customer is required o provide free access to all meters ono said property. Booneville Gas & Water Department complies with Mississippi Code Ann. #17-25-13(2015) - Procedure to assist in collection of delinquent water sewer service bills by counties, municipalities, and water sewer associations. If you excavate / dig on your property, please call MS One-Call at 811 or 1-800-227-6477 to have buried utilities located. This is a federal law, call before you dig. If an ASCO Garbage container is at the home it stays with it stays with the home and you do not take this container with you when you move. Statement of Financial Responsibility: Unless otherwise prohibited, I unconditionally guarantee payment in full to Bonneville Gas & Water Department, for services provided for me. I hereby authorize and consent to the release of all personal information (including but not limited to my home phone, cell phone, work phone, address, and email address) by Booneville Gas & Water or to the facility. This authorization shall remain in effect until such time as all account balances extending from the encounter have been fully satisfied. I authorize Booneville Gas & Water Department who have provided services, along with any billing service and their collection agency or attorney who may work on their behalf to contact me on my cell phone and/or home phone using pre-recorded messages, artificial voice messages, automatic telephone dialing devices or their computer assisted technology, or by electronic mail, text messaging or by any other form of electronic communication. I with this agree and understand, I the undersigned, will be responsible for the bill for services at the above address, or while on the Booneville Gas & Water System.DocumentsUpload Property Deed / Rental Lease AgreementMax. file size: 512 MB.Upload Driver's LicenseMax. file size: 512 MB.Customer AgreementConsent:(Required) I agree to the Booneville Gas & Water Department policy and procedures.Consent I agree to the Customer Information Packet that includes the Gas & Water Meter Access Policy issued by the Board of Alderman of Booneville, Mississippi.Customer Digital Signature(Required) CAPTCHA Download: Customer Information Packet Packet Download