Application for Residential Service

NOTE: All fields in RED are required. Depending upon the results of your credit check, you may be required to pay a deposit in full prior to electric service being connected.

Name


Last	First	Middle

Social Security #

(We request a SS# for credit verification purposes so that we can expedite your request for service.)

Spouse Name

Service Address

City

State

Zip

Mailing Address
if different from above

City

State

Zip

Home Phone #

Cell Phone #

Place of Employment

Employer's Phone #

Spouse's Employment

Spouse's Phone #

Type of New Service Requested:

GasElectric Propane

This form will save time in processing your request for services but a phone call is still required to complete the request. Please indicate a time frame and phone number when you would like us to call you - in order to make it as convenient for you as possible. Calls will be placed between 7:30 a.m. and 5:30 p.m. Monday through Friday.

Date

Time Frame

Phone #


Submitting this form authorizes The Energy Cooperative to perform a credit check based on the Social Security Number provided above.