Start/Stop Service

if applicable...

residence where service is being requested

(yyyy/mm/dd)


(yyyy/mm/dd)

(000-000-0000)

(000-000-0000)

(000-000-0000)


if joint membership

(yyyy/mm/dd)

(000-000-0000)


if different than above


Buying
Buying on Contract
Renting

(000-000-0000)

(000-000-0000)



Type your full name in all capital letters to confirm your digital signature.

Type your full name in all capital letters to confirm your digital signature.


 

The service connection fee will be $35.00 added to the first bill.

Please fax a copy of your driver's license to 812-738-2378
Please fax a note for the reason if this is a transfer (ex: Transfer 2222 Old Forest Rd. into my name as of 5/5/13 and sign your name).
REMC will contact you to complete a credit check. A security deposit may be required.


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