Commercial/Industrial Membership ApplicationApplicationRequested Service Connect Date MM slash DD slash YYYY Business Name(Required)Business Address(Required) Street Address Address Line 2 City 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 State ZIP Code Service Address (If Different) Street Address Address Line 2 City 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 State ZIP Code Business Phone No.(Required)Federal ID No.Facility Contact Name(Required) First Last Facility Contact Phone No.Facility Contact Email Facility Contact Address Same as previous Street Address Address Line 2 City 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 State ZIP Code Billing Contact Name First Last Billing Contact Email Billing Contact Phone No.Note: A security deposit may be required or a letter of credit received before service will be connected in the Consumer’s name. The deposit will be refunded as a credit on the 13th month after the deposit is paid in full if the account has no negative points for 12 consecutive months. Upon termination of service, the deposit will be applied to the final bill. Any outstanding balance remaining on the final bill after the deposit has been applied must be paid in full by the regular due date of the bill. Authorization(Required) 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 THIS APPLICATON AND UNDERSTAND THAT I AM RESPONSIBLE TO PAY COST OF COLLECTION ON DELINQUENT ACCOUNTS, WHICH COST MAY INCLUDE, BUT IS NOT LIMITED TO INTEREST, 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.(Required)Authorized Party First Last Date MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
