Your InformationAccount Number Date to Start Service (mm/dd/yyyy)(Required) Month Day Year Name(Required) First Last Driver's License(Required)Please submit a copy of your driver’s license for verification of identity. Thank you.Max. file size: 499 MB.Date of Birth (mm/dd/yyyy)(Required) MM slash DD slash YYYY Phone(Required)Social Security Number(Required)Add a Co Applicant?(Required) Yes No Co Applicant Name(Required) First Last Co Applicant Driver's License(Required)Please submit a copy of your driver’s license for verification of identity. Thank you.Max. file size: 499 MB.Co Applicant Date of Birth (mm/dd/yyyy)(Required) MM slash DD slash YYYY Co Applicant Phone(Required)Co Applicant Social Security Number(Required)Service Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address(Required) Same as Service Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Previous Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Employment InformationYour Employer(Required) Work PhoneAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Co Applicant's Employer(Required) Work PhoneAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Are you the property owner?(Required) Yes No Property Owner(Required) Property Owner Phone(Required)Do you want to participate in Operation Roundup?(Required)Operation Roundup is a voluntary program where participating members allow Henry County Rural Electric Membership Corporation (HCREMC) to “round up” their electric bills to the next whole dollar. For example, a bill for $63.75 would be rounded up to $64, and the 25¢ would be donated to the program. Annually, the average participating member contributes approximately $6 to the program. Yes No Property Meter is Serving(Required) Home Own Rent Barn Garage Campsite** Grain Bin** Other Township County **Non-permanent fees apply - Section/Township Range(Required)Must sign the Non-Permanent Service agreement. Consent(Required) The Applicant agrees to pay the sum of $25 for membership in the Co-op. In case this application is not accepted by the Co-op, the membership amount will be returned to the Applicant. In case of withdrawal or termination of membership in any manner, the Cooperative shall repay the member the amount of the membership paid by him, provided, however, that the Cooperative shall deduct from the amount of the membership fee the amount of any debts or obligations owed by the member to the Cooperative. When Co-op makes electric energy available to Applicant, Applicant agrees to purchase from the Co-op, and pay monthly to the Co-op, for all electric energy used on the premises now owned or occupied by the applicant, in accordance with the rules and regulations established by the Co-op. The Applicant hereby grants to the Co-op the right and easement to place, mark, construct, reconstruct, rephrase, inspect, operate, repair, maintain relocate and replace thereon, and in or upon all streets, roads, or highways abutting said lands, an electric distribution line or underground system, or any part thereof. To cut and trim or control the growth by chemical means, machinery or otherwise of trees, brush or shrubbery that may interfere with or threaten to endanger the operations and maintenance of said line or system, including any control of the growth of other vegetation in the right-of-way which may incidentally and necessarily result from the means of control employed, and to cut down from time to time all dead, weak or leaning trees. The Applicant will cause his premises to be wired in accordance with wiring specifications approved by the Co-op and National Electrical Code. The Applicant will comply with and be bound by the provisions of the by-laws and rules and regulations of the Co-op as may be adopted from time to time. The Co-op makes no guarantee that the member will receive uninterrupted service. The Applicant agrees to pay all prior and future bills owed to the Co-op. The Co-op reserves the right to charge a deposit. A consumer credit report may be requested from one or more consumer reporting agencies. Consumer credit reports may be used in connection with any update, renewal or extension of service requested by this application. The Applicant agrees to pay for any and all costs incurred by the Co-op as a result of Applicant's negligence (i.e. damage to lines) The undersigned certify that all statements made herein are true and correct and are to be relied upon by the Co-op and are made to induce the Co-op to extend service to the undersigned. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Applicant's Electronic Signature (Full Name)(Required) Co Applicant's Electronic Signature (Full Name)(Required) NameThis field is for validation purposes and should be left unchanged.
