CompanyThis field is for validation purposes and should be left unchanged.Member/ Service Location InformationName(Required) First Last Email(Required) Phone(Required)Perfered method for receiving information from our office(Required) Email Standard Mail Nearest Pole Number or Padmount Transformer NumberSubdivision(Required) Yes No Subdivision NameLot NumberIndicate if address below is service address or nearest address.(Required) Service Address Nearest Address 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 Check box if address above is the same as mailing address. Mailing 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 Service Type(Required) House Mobile Home Pole Barn/ Garage Shop Grain Bins Irrigation Commercial/Industrial/Business Hours of OperationDesired Service Orientation(Required) Overhead Underground Desired Service Size(Required) 200 A 320 A 400 A Other Desired Phasing/ Voltage (Single Phase) 120/240 V 240/480 V Desired Phasing/ Voltage (Three Phase) 120/208 V 120/240 V 480 V 277/480 V Projected Loading InformationTotal Connected LoadEstimated Peak Demand (kW)NotesConsent and Signature SectionUnderground Facilities Consent(Required) I understand and accept the following terms: The property owner shall provide a 12’ wide clear path, that is graded to within 4” of final grade, for the installation of the electric facilities. The property owner shall ensure that the facilities remain accessible to REMC’s equipment and remain free of obstructions. The property owner will be responsible for all relocate fees should the facilities become obstructed with any permanent or semi-permanent hindrances such as decks, pools, sheds, etc. REMC will not be responsible for damage or removal of vegetation during the installation, removal, or maintenance of underground facilities. All existing underground wires, septic systems, pipes, tiles, etc. owned by the property owner, that are within the flagged path, shall be dug up and exposed. REMC will not be liable for damage to property owners’ facilities that were not exposed. REMC retains the right to refuse underground service where ground conditions prohibit digging.Member Consent(Required) 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.Member Electronic Signature (Full Name)(Required)
