Business Application for Service

Business Information:

W-9 Business Name*

Federal Tax ID Number*

Business Type*

State of Incorporation/Formation:*

Business Phone Number*

Owner:

Owner Name*

First Middle Last

Social Security Number

Cell or Secondary Phone Number

Email

Authorized Representative(s):

First Authorized Representative

First Last

Title:

Second Authorized Representative

First Last

Title:

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Service Address (if different than above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Are you the property owner or renter?

Owner
Renter

If you are renting, please provide Landlord's name, address & phone number.

Property Description*

Residential/Rental
Agricultural/Commercial
Other

If "other" please describe:

Do you elect to be eligible for a discounted refund of patronage capital upon termination of membership as directed under #21 in the Membership Agreement?*

Yes
No

Have you received service from ACEC before?

Yes
No

I wish to participate in Operation Round-Up

Operation Round-Up allows you to round your bill up to the next dollar amount to support community projects. More information available on our website.

Yes
No

By electronically signing, you are applying for and agree to become a member of ACEC and to accept all terms and conditions of membership as provided in the "Membership Agreement". By submitting the Application, the Applicant is attesting that the information contained therein is true and correct to the best of the Applicant's knowledge. If any information furnished to the Cooperative is found to be false, the Cooperative may terminate Applicant's membership in the Cooperative, disconnect electric service, and pursue any other remedies provided by law.

I/We agree

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Name

This field is for validation purposes and should be left unchanged.

If satisfactory credit has not been established with the cooperative, a deposit is necessary.