APPLICATION FOR MEMBERSHIP

Please complete this application to apply for new service.

If you have any questions regarding setting up service, please contact our office (800) 637-8667, Monday – Friday, 8 a.m. – 4:30 p.m. All fields with the asterisk (*) are required.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Member First Name:   *
Member Last Name:   *
Member Middle Initial:   *
Social Security No:--  *
Driver’s License No.:  *
State Issued:   *
Date of Birth:  *  
Workplace:  

Mailing Address
Please enter the address where bills should be sent:
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address (911 Address Required)

Service Address:  
Comments:  
E-mail:  *
Confirm E-mail:  *
Primary Phone:--   *
Cell Phone:--  
Work Phone:--   
Joint Member Name:
(first and last name)		 
Social Security No:-- 
Driver’s License No:  
State Issued:  
Date of Birth:    
Workplace:  
Contact Number:  

Online Access
We offer a variety of online services that our customers may use through our website. As one of our services, we provide an online application for viewing and paying bills. Please specify an Internet Password and Password Hint at this time.
Internet Password:  *
Confirm Internet Password:  
Password Hint:

Existing Service
Have you ever had service with us before?    

Account Number:

Fee & Deposit Information

Residential Accounts:
All new applicants are required to pay a $15.00 fee for service to be connected. Based on credit rating, a security deposit may also be required. When your account is created, you will receive an email.

Business Accounts:
All new applicants are required to pay a $15.00 fee for service to be connected. A security deposit will be required. When your account is created, you will receive an email.

Connect Fee:  

Which Source of Heat Will You Use?
(enter Gas , Wood/Other, Electric Heat or Solar/Renewable)		  *
If Electric Heat, Heat Pump or Geothermal?  
If applicable, would you like the Outdoor Light On or Off?
(enter N/A for not applicable)		  *
If applicable, Name of Landlord:  
Please select your status at service location:   *
Please select your preferred Billing Method:   *
 
I agree to abide by the AGREEMENT FOR PURCHASE OF ELECTRIC SERVICE, provisions included in Southwestern Electric’s Certificate of Incorporation, and the bylaws of the Cooperative, as well as future bylaw amendments.
I understand that checking this box and typing my name in the field provided below is my electronic signature.;
  Member Name:     *