Northwestern Electric Cooperative

Service Application

Membership Application for Electric Service

I have read and understand the Service Terms.

Completing all of the fields below will insure faster processing.

First Name

M.I.

Last Name

Date of Birth (01-24-1968)
- -

Social Security Number (444-55-6666)
- -

Home Phone
( )

Work Phone
( )

Cell Phone
( )

Mailing Address

City

State

Zip Code

Driver's License Number

Former Member
Yes No

Your Employer

City

State

Zip Code

Spouse First Name

Spouse M.I.

Spouse Last Name

Spouse Social Security Number (444-55-6666)
- -

Preferred Connect Date (06-24-2000)
- -

Do You Own This Property?
Yes No

Name of Landlord (if you are a tenant at this account location)

Do You Rent This Property To Someone Else?
Yes No

If yes, your tenant may qualify for certain rights under APSC Rule 6,19, "Provisions for Landlords and Tenants."

Name of Tenant (if you are landlord)

Elderly
Yes No

Handicapped
Yes No

Location of Account (if different from mailing address)

Meter Number

Security Light
Yes No

In applying for membership service with Northwestern Electric Cooperative, I am applying to receive electric service at the location described above. I agree to conform to and abide by the bylaws and regulations as provided by the Board of Directors of the Cooperative, as now exists or as may hereafter be adopted.

E-mail address

Signature
(type in your name as you would sign it)

Co-Applicant Signature
(type in your name as you would sign it)

Would you like to be added to our e-mail list?
Yes No

Would you like to sign-up for Automatic Bank Draft? If you answer yes to this question and after you submit this form you will be prompted with a link to the Automatic Bank Draft Form page.
Yes No

STATEMENT OF NONDISCRIMINATION

Northwestern Electric Cooperative, Inc. is the recipient of Federal financial assistance from the Rural Utilities Service, an agency of the U.S. Department of Agriculture, and is subject to the provisions of Title VI of the Civil Rights Act of 1964, as amended, Section 504 of the Rehabilitation Act of 1973, as amended and the Age Discrimination Act of 1975, as amended and the rules and regulations of the U.S. Department of Agriculture. In accordance with the Federal law and the U.S. Department of Agriculture’s policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, religion, age, or disability (Not all prohibited bases apply to all programs).

The person responsible for coordinating this organization’s nondiscrimination compliance efforts is Frankie D. Tuck, Chief Executive Officer. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410, or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer. Confidentiality will be maintained to the extent possible.

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