Has premises  been previously supplied with electric service:                         □ yes                     □ no

                 Type of Service:              □ Residential                    □ Commercial                   □ Agricultural

 Customer (s) name:                                                                                       SSN or Fed Tax ID:                                                         

Service Address/Location:                                                                                                                                                                      

City/State/Zip:                                                                                                                                                                                                 

Home Telephone:                                                                                            Work Telephone:                                                          

Billing Address:                                                                                                                                                                                            

(If different from service address)

City/State/Zip:                                                                                                                                                                                                 

Employer Name:                                                                                                                                                                                             

Employer Address:                                                                                                                                                                                      

CITY/STATE/ZIP:                                                                                                                                                                                                  

If this is a commercial account, please list:

Accounts Payable Contact:                                                    Accounts Payable Telephone:                                              

Are there any types of life support systems used in home   □ yes                     □ no

If yes, what type:                                                                                                                                                          

 

In case of emergency please contact:                                                                                                             

                Relationship to account holder:                                                                                                       

                Telephone Number:                                                                                                                                      

Please read and sign below:

I certify under the penalty of perjury that all information provided herein is true and

correct to the best of my knowledge.

 

Applicant’s Signature:                                                                                                                               Date: