Electrical Service Application

Name of previous homeowner (if applicable):
Address of residence where service is being requested:*
City:*
State:*
Zip:*
Requested date for service to begin: (mm/dd/yyyy)*

Name:*
E-mail Address
Last 4 digits of SSN:*
DOB: (mm/dd/yyyy)*
Employer:
Work Phone: (000-000-0000)
Cell Phone: (000-000-0000)
Home Phone: (000-000-0000)*

2nd Party(if joint membership):
2nd Party Last 4 digits of SSN:
2nd Party DOB: (mm/dd/yyyy)
2nd Party Employer:
2nd Work Phone: (000-000-0000)

Mailing Address (if different than above):
City:
State:
Zip:

Please indicate which of the following applies to the residence where you are requesting service:*
Buying Buying on Contract Renting

If renting or buying on contract, please indicate the owner's full name:
Owner's Phone Number: (000-000-0000)
Name of Friend or Relative:
Friend or Relative Phone Number: (000-000-0000)

Have you ever been a member of Harrison REMC:	Yes No
If yes, when?

Customer Signature (Check to indicate your signature):
2nd Party Signature (Check to indicate your signature):

The service connection fee will be $30.00 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 5/5/10 and sign your name.) REMC will contact you to complete a credit check. A security deposit may be required.

(812) 738-4115
(812) 951-2323