Residential Membership Application

Membership Information


Customer Information




Service Information


Reference Information


Previous Membership Information


Utility Information

Note: Please complete this application in full. A security deposit may be required and must be paid in part or in full at the time service is requested. If partial payment is made, the balance of the deposit is due and payable in full upon receipt and payment of your first monthly bill, or service will be disconnected. Disconnection will occur in a timely fashion according to normal disconnect procedure for nonpayment.

EVERYTHING I HAVE STATED IN THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. I HEREBY AUTHORIZE YOU TO INVESTIGATE MY CREDIT RECORD. I AGREE TO THE TERMS SET FORTH IN THE APPLICATION AND UNDERSTAND THAT I AM RESPONSIBLE TO PAY COSTS OF COLLECTION ON DELIQUENT ACCOUNTS, WHICH COSTS MAY INCLUDE, BUT ARE NOT LIMITED TO INTERESTS, COURT COSTS, COLLECTION AGENCY FEES AND REASONABLE LEGAL FEES. I AUTHORIZE YOU TO CALL ME AT ANY OF THE PHONE NUMBERS I PROVIDED TO YOU.

This institution is an equal opportunity provider and employer.