Town of Mocksville

Application for Service

Water|Sewer|Trash

You may complete this form online to create an account (see below online form) or download and print a copy here.

To fill out online, please have the following documents available:

Driver’s license
Lease agreement, if renter
Property deed or closing document, if owner

Renters may pay the $200 deposit in cash, check, or with a credit card – visit the office or mail payment to:

Town of Mocksville
171 S. Clement Street
Mocksville, NC 27028

The deposit is waived with proof of ownership.

If you have questions please call 336-753-6700 or email HERE.

Application for Water | Sewer| Trash Services

This form is an online application for water, sewer and trash services provided by the Town of Mocksville.

Date

Resident Information

Owner

Renter

Services Provided

Water

Sewer

Trash

Applicant's Name(Required)

First Last

Property Deed or Copy of Closing Document - If Owner

Please upload a copy of your deed or closing document in order for your deposit/activation fees to be waived.

Drop files here or

Accepted file types: pdf, jpg, jpeg, tiff, gif, Max. file size: 32 MB.

Landlord's Name (if renting)

First Last

Landlord's Phone

Copy of Lease Agreement

Please upload a copy of your lease agreement if you are renting.

Drop files here or

Accepted file types: pdf, jpeg, jpg, gif, tiff, Max. file size: 32 MB.

Service Address (to connect)(Required)

Please include the apartment or suite number in the address line if applicable.

Street Address Address Line 2 City State ZIP Code

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Driver's License Number

Include BOTH the license number and the state that issued it.

Social Security Number

Used to verify identity and debt collection.

Date of Birth

Contact Phone

Work Phone

Contact Email

Name of Emergency Contact

First Last

Emergency Contact Phone

Co-applicant Name (if applicable)

First Last

Co-applicant's Social Security Number

Used to verify identity and debt collection

Co-applicant's Driver's License Number & State

Please include the co-applicant's license number and the state that issued it.

Co-applicant's Date of Birth

Co-applicant's Contact Number

Co-applicant's Work Number

Co-applicant's Email

Driver's License Copy - Applicant & Co-applicant

Please upload a copy of driver's licenses for both the applicant and co-applicant.

Drop files here or

Accepted file types: pdf, jpeg, jpg, gif, tiff, png, Max. file size: 32 MB.

Co-applicant's Signature

Applicant's Signature(Required)

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Application for Services

Town of Mocksville

Application for Service

Water|Sewer|Trash

Application for Water | Sewer| Trash Services