Residential Application

Primary Applicant

Name*

First Middle Last Suffix

Social Security #:*

Date of Birth*

Primary Phone #:*

Secondary Phone #:

Email Address:*

Employer:*

Phone Number #:*

Is there a co-applicant?*

Yes

No

Co-Applicant

Name*

First Middle Last Suffix

Social Security #:*

Date of Birth*

Primary Phone #:*

Secondary Phone #:

Email Address:

Employer*

Phone Number #:*

Location

Service Location #(6-digit, hyphenated number on meter)

Physical Address:

Street Address City ZIP / Postal Code

Please select one of the following:

Buying

Renting/Leasing

If renting/leasing from whom:

Phone Number #:

Billing Address (if different than service location):

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

Applicant's Previous Address:

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

Emergency Contact Name:

Relationship:

Phone Number #:

Applicant Consent*

I hereby verify the below information to be true and complete and agree to the terms and conditions listed below. I understand that by typing my full name below and pressing the Submit button below, this application will be stamped with today’s date and authorized by me as if I had signed my Signature.

1. The undersigned (hereinafter called the Applicant) agrees to comply with and be bound by the Articles of Incorporation of Cooperative, the By-Laws of Cooperative and any amendments thereto, and such Rules and Regulations as may be adopted from time to time by Cooperative. Applicant authorizes payment of annual subscription to The Monthly Newsletter/Magazine from the amount accruing to him each year.

2. Applicant agrees, when electric service becomes available, that all electric energy used on the premise will be purchased from Cooperative and will be paid therefor monthly at rates to be determined from time to time in accordance with the By-Laws of Cooperative.

3. Applicant agrees:

a. To make payment of such fee as is designated in the Rules and Regulations which are incidental to providing electric energy at service connection and in the event of default, to pay court costs, attorney fees, and reasonable collection agency fees of 35%, incurred in collection of the past due amount.

b. That any fees specified in above (a) are refundable in the event this application is not accepted by the
Board of Directors.

4. Applicant agrees to deposit with Cooperative such consumer deposit that may be required by the By-Laws and
Policies of the Cooperative:

a. Any portion of said deposit not applied to payment of electric bills due Cooperative will be returned to
applicant either:

i. Upon termination of service or
ii. If service has not been terminated, refund will be made at Cooperative’s discretion.

5. Applicant agrees to receive notices/correspondence from the cooperative by text, email, or automated telephone calls as approved by the Federal Communications Commission (FCC).

6. The acceptance of this application by Cooperative shall constitute an acceptance to membership in Cooperative
with such rights and liabilities as are specified in the By-Laws of Cooperative, provided, however, that said membership shall terminate when Applicant ceases to purchase electric energy from Cooperative.

7. Applicant, by becoming a member, assumes no personal liability or responsibility for any debts or liabilities of Cooperative, and it is expressly understood that under law his private property cannot be attached for any such debt or liabilities.

As a member of the Cooperative you have an opportunity to participate in our Operation Round Up® program. You have automatically been enrolled in the program and may at any time contact the office to opt-out. The Operation Round Up® program allows us to round up your electric bill to the next highest dollar and apply that money to the Operation Round Up® program which funds projects for the betterment of your community.

I/We do hereby certify that the information provided is true and correct to the best of my /our knowledge. I/We do hereby authorize you to investigate my/our credit record.

Member: $8.57 of your yearly electric bill will be allocated for a subscription to Indiana Connection magazine.

Applicant's Electronic Signature (Full Name)*

Note: If the credit report is not satisfactory, you will be given the option to make a cash deposit or sign up for pre-pay metering.

Please upload a photo copy of Applicant's driver's license.*

Max. file size: 30 MB.

Co-Applicant Consent

I hereby verify the below 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.

1. The undersigned (hereinafter called the Applicant) agrees to comply with and be bound by the Articles of Incorporation of Cooperative, the By-Laws of Cooperative and any amendments thereto, and such Rules and Regulations as may be adopted from time to time by Cooperative. Applicant authorizes payment of annual subscription to The Monthly Newsletter/Magazine from the amount accruing to him each year.

2. Applicant agrees, when electric service becomes available, that all electric energy used on the premise will be purchased from Cooperative and will be paid therefor monthly at rates to be determined from time to time in accordance with the By-Laws of Cooperative.

3. Applicant agrees:

a. To make payment of such fee as is designated in the Rules and Regulations which are incidental to providing electric energy at service connection and in the event of default, to pay court costs, attorney fees, and reasonable collection agency fees of 35%, incurred in collection of the past due amount.

b. That any fees specified in above (a) are refundable in the event this application is not accepted by the
Board of Directors.

4. Applicant agrees to deposit with Cooperative such consumer deposit that may be required by the By-Laws and
Policies of the Cooperative:

a. Any portion of said deposit not applied to payment of electric bills due Cooperative will be returned to
applicant either:

i. Upon termination of service or
ii. If service has not been terminated, refund will be made at Cooperative’s discretion.

5. Applicant agrees to receive notices/correspondence from the cooperative by text, email, or automated telephone calls as approved by the Federal Communications Commission (FCC).

6. The acceptance of this application by Cooperative shall constitute an acceptance to membership in Cooperative
with such rights and liabilities as are specified in the By-Laws of Cooperative, provided, however, that said membership shall terminate when Applicant ceases to purchase electric energy from Cooperative.

7. Applicant, by becoming a member, assumes no personal liability or responsibility for any debts or liabilities of Cooperative, and it is expressly understood that under law his private property cannot be attached for any such debt or liabilities.

As a member of the Cooperative you have an opportunity to participate in our Operation Round Up® program. You have automatically been enrolled in the program and may at any time contact the office to opt-out. The Operation Round Up® program allows us to round up your electric bill to the next highest dollar and apply that money to the Operation Round Up® program which funds projects for the betterment of your community.

I/We do hereby certify that the information provided is true and correct to the best of my /our knowledge. I/We do hereby authorize you to investigate my/our credit record.

Member: $8.62 of your yearly electric bill will be allocated for a subscription to Indiana Connection magazine.

Note: If the credit report is not satisfactory, you will be given the option to make a cash deposit or sign up for pre-pay metering.

Co-Applicant's Electronic Signature (Full Name)

Please upload a photo copy of Co-Applicant's driver's license.

Max. file size: 30 MB.

Hidden

For Office Use Only:

Applicant's Photo ID Received

Co-Applicant's Photo ID Received

Customer Number: ________________

Data Collection Information*

The following information is requested by the Federal Government for certain types of loans, in order to monitor the lender’s compliance with equal credit opportunity. You are not required to furnish this information but are encouraged to do so. The law requires that a lender may neither discriminate based on this information nor on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations, this lender is required to note race/ethnicity on the basis of visual observation or surname.

Should you have any questions, you may contact our office at 800-323-2316.

Thank you for your cooperation in this matter.

Race/Ethnic Group (Please check one of the following):*

White (not of Hispanic origin)

Black (not of Hispanic origin)

Hispanic

American Indian or Alaskan Native

Asian or Pacific Islander

Name*

First Last

Date*