Membership Application

Please read the agreement above before submitting this form. Your digital signature is required to complete the form.

Company Name
Title
Name Name First Last
Billing Address Billing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Fax Number Fax Number - ### - ### ####
Email
Billing Information
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Enter the mailing address where mail will need to be sent regarding the One-Call Center
Physical Address Physical Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Enter the physical address of the field office located in Mississippi, if different than mailing address
Member Type

Member Type Cable Crude Product Electricity Fiber Gas Transmission Locator Phone Rural Water Sewer Traffic Water Other

Which best describes your company from the following list? You can choose more than one, if needed
If other, please list
Contact Person Contact Person First Last
Contact information for the person that will handle locate requests
Contact Email
Contact Phone Contact Phone - ### - ### ####
DB Contact same as Contact Person
Database Contact Database Contact First Last
Contact name for person handling the record-keeing for the location of the underground facilities and keeping the One-Call System updated with any additions or deletions to the underground facilities
Database Contact Email
Database Contact Phone Database Contact Phone - ### - ### ####
Positive Response Contact Positive Response Contact First Last
Contact information for the person that will handle submitting positive response.
Contact Email
Contact Phone Contact Phone - ### - ### ####
After Hours Emergency Contact 1 After Hours Emergency Contact 1 First Last
The person to contact in the event of an after hours emergency
Contact 1 Phone Number Contact 1 Phone Number - ### - ### ####
After Hours Emergency Contact 2 After Hours Emergency Contact 2 First Last
Contact 2 Phone Number Contact 2 Phone Number - ### - ### ####
Spatial Database Buffer

As we build your spacial database, what size buffer is needed around the underground facilities? Minimum = 400 ft
Operating Counties

Mississippi counties in which your company has underground utilities
Maps

Do you need maps of the counties to draw your facilities?
Method of Receiving Locates
Fax

Fax Fax
Fax Number Fax Number - ### - ### ####
E-mail

E-mail E-mail
Email Address
Backup Fax Number Backup Fax Number - ### - ### ####

Required if using E-mail option
How do you want your e-mail tickets sent?

How do you want your e-mail tickets sent? Batch tickets on single e-mail Single e-mail per ticket as attachment Single e-mail per ticket as body
FTP

FTP FTP Site
Site address

Ex. ftp.ms1call.org
Username
Password
Remote directory name (if needed)
Text Message

Text Message Text message

Emergency locates only. You must choose at least one other mode of receiving locates.
Mobile phone number Mobile phone number - ### - ### ####
Carrier

Ex. AT&T, Verizon, or Sprint
Contract Locating Service

Contract Locating Service Contract Locating Service
Contract Locating Service Name
Contact Person
Contact Phone Contact Phone - ### - ### ####
KorWeb

KorWeb KorWeb
By digitally signing, I am giving MS811 authorization to transmit locate request to mode(s) listed above for the company listed as part of the member set up.
Digital Signature

Entering your name here will serve as a digital signature exemplifying acceptance of this agreement by your company.

Membership Application

Membership Application

Billing Information

Method of Receiving Locates

By digitally signing, I am giving MS811 authorization to transmit locate request to mode(s) listed above for the company listed as part of the member set up.