Fillable RESIDENTIAL APPLICATION FOR SERVICE

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RESIDENTIAL APPLICATION FOR SERVICE

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The RESIDENTIAL APPLICATION FOR SERVICE form is 3 pages long and contains:

  • 4 signatures
  • 23 check-boxes
  • 46 other fields

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File type: PDF

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RESIDENTIAL APPLICATION FOR SERVICE
CONTINUED ON NEXT PAGE
Page 1 of 3
Application Date Apt. / SuiteService Location Physical Address (Street, City, State, Zip)
Requested Service Start Date
Owner Tenant
Landlord
Landlord’s Name
Tenant’s Name
Billing Address (City, State, Zip) Previous Address (City, State, Zip)
Primary Phone Number
Place of Employment
Additional Phone Number
Work Phone Number
Applicant Name (Last, First, Middle)
Date of Birth
Social Security Number
ID No. (Driver’s License, State ID, Military ID, Passport, or I-551)
Email address
Primary Phone Number
Place of Employment
Additional Phone Number
Work Phone Number
Co-Applicant Name (Last, First, Middle)
Date of Birth
Email address
CECC USE ONLY
Account Location No.
Member Sep. Member No.
Mark the box(es) if
your account should
be marked as:
If there is a SECURITY LIGHT at this
location, would you like to keep it?
Age 65 or Older
Yes No
Handicapped
(Doctor’s certication required - certication from a physician,
licensed psychologist, by the United States Veteran’s Administration, the Social
Security Administration, the Arkansas Department of Human Services, the
Arkansas State Hospital, or a licensed mental health center.)
Social Security Number
ID No. (Driver’s License, State ID, Military ID, Passport, or I-551)
Yes No (If No, complete New Construction section on page 2.)
Has there ever been electric service at this location?
I am a(n):
eBilling email address
Must establish myAccount ID and password to view bills.
See myaccount.carrollecc.com for details.
Please enroll me in eBILLING
eSERVICES
Bank Routing Number (max 9 numbers)
Name(s) on Bank Account
Bank Name
Bank Account Number
(max 15 numbers)
Bank City, State
Please enroll me in eDRAFT
Checking
Savings
I authorize Carroll Electric to electronically debit my account monthly, for the amount stated on my bill(s) and if necessary, electronically credit my account to correct erroneous debits.
I understand this authorization remains in full force and effect until I notify Carroll Electric in writing, at least ve days before the due date. Cancellation instructions are available at
carrollecc.com or by calling 1-800-432-9720.
Use the information above to electronically debit my exisiting accounts (existing members only.)
Page 2 of 3
COMPLETE THIS PAGE ONLY IF APPLYING FOR SERVICE AT A NEW CONSTRUCTION SITE
Property Description (Lot, Block, Phase, Subdivision, etc.)
What type of structure will this serve? (House, shop, boat dock, etc.)
Is the following installed at this site? If No, additional costs will apply for an unqualied load.
Sanitary Sewer
City
Septic
No
No
Well
Yes
No
Permanent Foundation
Sanitation System
Pressurized Water System
200 AMP Meter Base - $190.53
Turnkey Installation (signed release form required)
• 200-amp main breaker
• 20-amp circuit breaker
• GFCI outlet
• Slip joint for permanent power
400 AMP Meter Base - $707.97
Turnkey Installation (signed release form required)
• Two 200-amp main breakers
• 20-amp circuit breaker
• GFCI outlet
• Slip joints (2) for permanent power
Carroll Electric’s standard pedestal installation provides the following options (please select a meter base package):
Meter Base Package Release
I hereby acknowledge receipt of and accept full ownership of the described material(s) from Carroll Electric Cooperative Corporation
(the “Cooperative”) upon the following terms and conditions:
Upon installation by the Cooperative. I assume full responsibility and control of all material(s) obtained hereunder. Any costs for repair,
replacement, or removal of the material(s) shall be at my expense. I understand that a licensed electrician should be the only party
who repairs, replaces, or removes the materials. If the materials are installed in an area where an ofcial inspection is required by any
government agency, or any county, city, or other controlling entity, I agree that I am completely responsible for having the materials
and/or installation inspected by an appropriate expert. The Cooperative will work with all local inspection ofces to ensure a proper
installation.
I agree to indemnify and save and hold the Cooperative harmless from any liability from any cause whatsoever that might be claimed
by me, any subsequent owner, or any person or entity, claiming damages by virtue of or in any manner arising out of a defect in the
material(s), the use or condition of the material(s), or any other function or circumstances relating to the material(s). In the event any
legal action is brought against the Cooperative by any party for any reason regarding a defect in the material(s), the use or condition of
the material(s), or any other function or circumstances relating to the material(s), the undersigned agrees to reimburse the Cooperative
for any and all costs, charges, expenses, judgments, or otherwise, together with its attorney’s fees and costs, to investigate and/or
defend such claims.
Applicant Signature: Date:
Co-Applicant Signature: Date:
To add a new Security Light, please refer to the information below:
I would like to have (a) security light(s) installed at my new service location and agree to pay the $50.00 light connect fee(s)
and the associated monthly service fee(s). Carroll Electric offers the following light for residential use:
• LED - Standard Residential Wattage - $10.30
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The Applicant, whose signature appears below, applies to the CARROLL ELECTRIC COOPERATIVE CORPORATION of Berryville, Arkansas, (hereinafter called the “Cooperative”) for
membership and/or electric service to be supplied at the location herein described and, upon request, at any other location within the area served by this Cooperative. This agreement shall
supersede and replace any previous agreement and shall apply to each location the Cooperative furnishes electric service to the applicant.
The Applicant agrees to be bound by and to comply with all Rules of the Arkansas Public Service Commission (APSC), other applicable laws and regulations, as well as the Cooperative’s
approved tariffs, Articles of Incorporation, Bylaws, consumer classications, rates, charges, and service rules and regulations and all other applicable terms and conditions set by the
Cooperative, both as the same now exists or may hereafter be adopted, repealed, amended, or supplemented; to pay all fees, deposits, and charges in accordance with the rates, rules, and
regulations as now exist or as may hereafter be adopted; and authorizes the Cooperative to verify information provided, including the use of any credit reporting agency to verify identity.
The Cooperative shall operate on a not-for-prot basis as dened by law. As such, all patronage capital, if any, shall be held by the Cooperative in accordance with Ark. Code Ann. §23-18-327
until such time as determined by the Cooperative. In the event the Cooperative disburses patronage capital, it shall remain the Applicant’s responsibility to keep the Cooperative informed of
Applicant’s mailing address.
In the event the Applicant’s account becomes delinquent, the Cooperative shall follow the rules and tariffs approved by APSC and thereafter, the Applicant agrees to surrender the membership
fee, deposit, and future patronage capital to extinguish such indebtedness plus any accumulated late charges and interest. Further, the Applicant agrees to pay all cost of collection including
attorney’s fees, collection fees, and any other related fees and costs.
The Applicant will cause and keep his premises to be wired in accordance with wiring specications of the appropriate governing jurisdiction and the Cooperative assumes no responsibility for
loss or damage due to defective wiring and/or equipment located on the Applicant’s side of the meter installation or other agreed to point of delivery.
The applicant understands that the Cooperative shall use reasonable diligence to provide a constant and uninterrupted supply of electric power and energy hereunder. If the supply of electric
power and energy shall fail or be interrupted, or become defective through acts of God, governmental authority, action of the elements, public enemy, epidemic/pandemic, cyber-attack,
accident, strikes, labor troubles, required maintenance work, inability to serve right-of-way, equipment failure, or any cause beyond the reasonable control of the Cooperative, the Cooperative
shall not be liable therefore or for damages caused thereby.
Electric service shall be supplied within the voltage range prescribed by Arkansas Public Service Commission’s Special Rules - Electric. The Cooperative’s standard service voltage will be
120/240 volts, AC, unless otherwise stated in accordance with the approved schedules, rules, regulations, or by mutual agreement. However, in all cases, the voltage supplied to the Applicant
may vary by ± 5 percent measured at the meter. Voltage variations in excess of those specied shall not be considered a violation if variations are caused by:
(1) The operation of power equipment on a customer’s premises;
(2) The action of the elements; or,
(3) Infrequent and unavoidable uctuations of short duration in station operation.
The Applicant hereby recognizes the need for the Cooperative to maintain its facilities along all easements. All easements presently installed on the Applicants property, whether recorded,
written, or prescriptive, are approved and granted in favor of the Cooperative.
The Applicant agrees SECURITY DEPOSITS are subject to the rules of the APSC and are subject to the following conditions:
(1) Residential or personal deposits shall be waived or refunded based on the Applicant’s timely payment history dened by the APSC and evidenced by a certication letter from a
previous utility, a third-party personal guarantee from another qualifying individual, or other personal credit measurements determined by the Cooperative.
(2) Commercial deposits, surety bonds, or irrevocable letters of credit shall be provided by the Applicant to the Cooperative and shall remain in effect for the duration of service. Should
a commercial account not have a corporate taxpayer identication number issued by the Internal Revenue Service, the Cooperative shall also require a personal guarantee from the
Applicant’s principal business owner(s).
I understand that information on this application may be used for the purpose of a credit check and depending on the results of that credit check, I may be required to pay a deposit in full prior
to electric service being connected. I hereby authorize the Cooperative along with the Cooperative’s afliates and/or service providers to obtain a credit report from any reputable credit reporting
agency.
Maintaining a valid phone number will help both members and the Cooperative in reporting and restoring outages. Further, it may be necessary at times to contact members by phone
electronically or otherwise regarding your account. In keeping with the provisions of the Telephone Consumer Protection Act (TCPA), 47 U.S.C. § 227, the Cooperative requires your
express written consent prior to contacting you by telephone, facsimile, or text message for any non-emergency purpose using any automated telephone dialing system (ATDS) or articial or
prerecorded voice (each, an “Automated Method”). Your rights under the TCPA can be found at www.carrollecc.com/tcpa-rights or upon request. Should you choose to withhold or subsequently
revoke your consent pursuant to the TCPA, or otherwise refuse to provide a valid phone number, it is with the understanding that we might not be able to reach you regarding important
information about your electric service. By signing where indicated below, I authorize the Cooperative, along with the Cooperative’s afliates and/or service providers, to contact me using email
and/or any Automated Method of the Cooperative’s choosing, at the phone number and/or email address provided by me.
I HEREBY APPLY TO THE CARROLL ELECTRIC COOPERATIVE CORPORATION FOR MEMBERSHIP AND/OR ELECTRIC SERVICE IN
ACCORDANCE WITH THE TERMS AND CONDITIONS APPEARING ABOVE.
Applicant Signature: Date:
Co-Applicant Signature: Date:
Page 3 of 3
CECC USE ONLY
Account Location No.
Member Sep. Member No.
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RESIDENTIAL APPLICATION FOR SERVICE

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Completed 3 December 2021

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