Member InformationName(Required) Prefix Dr.MissMr.Mrs.Ms.Prof.Rev. First Last Social Security Number(Required) Alias, Nickname, or Maiden Name Birth Date (mm/dd/yyyy)(Required) Month Day Year Mailing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone(Required)Home PhoneFaxEmail Do you have a co-applicant?(Required) Yes No Name(Required) First Last Social Security Number(Required) Alias, Nickname, or Maiden Name Birth Date (mm/dd/yyyy)(Required) Month Day Year Signature & Consent Read the full Terms & Conditions of Service.Applicant Consent(Required) I hereby verify the above information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature. People’s electric cooperative shall use its best efforts to furnish its members with adequate and dependable electric service, although it cannot and, therefore, does not guarantee a continuous and uniterrupted supply thereof. Upon signing, applicant and/or co-applicant confirms all information provided herein is truthful and accurate, and also agree to be bound by such rules, bylaws, terms and conditions of service, and regulations as may from time to time be adopted by the cooperative. This signed form will serve as a certificate of membership. By signing, the applicant and/or co-applicant authorizes the cooperative to seek past credit history and to release credit history for future inquiries.Applicant & Co-Applicant Consent(Required) We hereby verify the above information to be true and complete and agree to the terms and conditions. We understand that by typing our full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by us as if we had signed our signature.People’s electric cooperative shall use its best efforts to furnish its members with adequate and dependable electric service, although it cannot and, therefore, does not guarantee a continuous and uniterrupted supply thereof. Upon signing, applicant and/or co-applicant confirms all information provided herein is truthful and accurate, and also agree to be bound by such rules, bylaws, terms and conditions of service, and regulations as may from time to time be adopted by the cooperative. This signed form will serve as a certificate of membership. By signing, the applicant and/or co-applicant authorizes the cooperative to seek past credit history and to release credit history for future inquiries.Account Number(Required)Applicant Electronic Signature (Full Name)(Required) Co-Applicant Electronic Signature (Full Name)(Required)
