Pay a Bill / Report an Outage  |  Start Service  |  Peak Day Status

Customer Information
Mr.
Mrs.
Ms.
S.S.#:
Alias
Nickname
Maiden Name
Date of Birth:
Spouse
Co-Applicant
Other
S.S.#:
Alias
Nickname
Maiden Name
Date of Birth:
Mail Bill To: STREET CITY STATE ZIP
Prop. Physical Address: STREET CITY STATE ZIP
Home Telephone Number: () -    OR    Message Number: () -
Mobile Number: () - Fax Number: () -
Internet/E-Mail Address:
Applicant Employed By: NAME ADDRESS TELEPHONE    () -
(None if not employed)
Co-Applicant Employed By: NAME ADDRESS TELEPHONE    () -
Bank: NAME ADDRESS CITY STATE
Bank Account Number: Savings Checking
Nearest Relative (Not Living in Household): NAME RELATIONSHIP
Address: Home Telephone Number: () -
Other Relative: NAME RELATIONSHIP
Address: Home Telephone Number: () -
Do you own or rent this location? Own Property Rent/Lease Landlord's Name (if renting)
Will you reside at this location? Yes No Please provide any Meter or Pole Tag ID
numbers at the location(s) to connect/transfer:
What Date will you be taking over the service? Would you like a security light connected at this location? Yes No
(Security light cost is $4 per month plus the cost of monthly energy usage if installed on existing PEC poles.)
Name of Last Resident? (If Known) Comments
Previous Address for Past Three Years:
STREET CITY STATE & ZIP CODE HOW LONG?
STREET CITY STATE & ZIP CODE HOW LONG?
I/We certifies that the information provided is correct and authorizes the Cooperative to seek past credit history and to release credit history for future inquiries. Consumer agrees to the terms of this Application and Agreement on today's date