Residential Service Application

Step 1 of 3

Customer Information
Name(Required)
Prefix 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 ZIP Code
Cell Phone(Required)
Home Phone
Fax
Email(Required)
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

Location Information
Do you own or rent this location?(Required)
- Own Property
- Rent/Lease
Landlord Name(Required)
First Last
Will you this location be your primary residence?(Required)
- Yes
- No
Please provide any Meter or Pole Tag ID numbers at the location(s) to connect/transfer:
Date you will be taking over service:(Required)
Please allow up to 72 hours for processing.
MM slash DD slash YYYY
Physical Property Address(Required)
Street Address Address Line 2 City State ZIP Code
Property Description
i.e. house, shop, cabin, etc.

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.
Applicant Electronic Signature (Full Name)(Required)
Co-Applicant Electronic Signature (Full Name)(Required)

Step 1 of 3

Customer Information

Location Information

Signature & Consent