Fillable SERVICE APPLICATION FORM

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SERVICE APPLICATION FORM

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SERVICE APPLICATION FORM
FLEX PAY ACCOUNT
POST PAY ACCOUNT
$
SERVICE ADDRESS
DATE SERVICE REQUESTED
EMAIL ADDRESS
FIRST NAME
MIDDLE INITIAL
LAST NAME
Mailing Address
SOCIAL SECURITY NUMBER
DL NUMBER & STATE
DOB
EMPLOYER NAME
ADDRESS
SPOUSE’S NAME
PHONE NUMBER
SOCIAL SECURITY NUMBER
DL NUMBER & STATE
DOB
EMPLOYER NAME
ADDRESS
CERTIFICATE OF MEMBERSHIP
I, ___________________________, (hereinafter called "applicant") hereby apply for membership in and agree to purchase electric energy from APPALACHIAN ELECTRIC
COOPERATIVE, Jefferson City, Tennessee, (hereinafter call "Cooperative") to be supplied at any address served by said Cooperative.
1. The applicant agrees to pay for said services as bills are rendered therefore, in accordance with the By-Laws of the Cooperative. Rules and Regulations as may be
adopted from time to time by the Cooperative, and rates in effect at the time of the delivery of service.
2. The applicant agrees, when electric service becomes available, that all electric energy used on the premises will be purchased from the Cooperative and will be paid
for at rates currently in effect or as amended from time to time provided, however, that the Cooperative may limit the consumption of electric energy which it shall
be required to furnish the applicant.
3. The applicant agrees that a bill of at least $__________________________ per month will be paid regardless of the number of kilowatt hours consumed and that
this instrument must be considered as a ______________________ year agreement when this section is completed.
4. The applicant agrees to (a) make payment of such membership fee as required by the Cooperative By-Laws, their amendments, and/or Rules and Regulations in
respect to said membership; (b) make such deposits with the Cooperative as may be required by the Cooperative's Rules and Regulations. The acceptance of this
application by the Cooperative shall constitute an agreement between the applicant and Cooperative and the contract for electric service shall continue in force until
cancelled by either party in accordance with the By-Laws and Rules and Regulations of the Cooperative.
5. The applicant, by becoming a member, assumes no personal liability or responsibility for debts or liabilities of Cooperative and it is expressly understood that, under
law, his private property cannot be attached for any such debts or liabilities.
TERMS OF MEMBERSHIP
This membership and all rights and privileges thereto shall begin upon applicants acceptance as a member by the Cooperative Board of
Directors and continue as long as (a) the member purchases electric energy from the service connection designed in said person's application
for membership; and (b) complies with the terms and conditions in respect to membership contained in the By-Laws of the Cooperative and
any amendments thereto and such Rules and Regulations as are adopted from time to time by the Board of Directors.
By: _______________________________ President ___________________________________________________Secretary
THIS MEMBERSHIP IS NOT TRANSFERRABLE. Obligations Accruing to the Cooperative are the Responsibility of the Within Named Member.
BY SIGNING I AGREE THAT ALL THE ABOVE INFORMATION IS CORRECT
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SERVICE APPLICATION FORM

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Completed 17 February 2021

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