- People's Electric Cooperative

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?

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