APPLICATION FOR MEMBERSHIP

(Please note that a credit check will be performed when applicable)

Any applications filled out after 4:30 p.m. Monday - Friday will be processed the next business day.

For locations that have had prior electric service, we offer same day service for an additional non-refundable $50 charge before 2 p.m.

Otherwise, applications received after 2 p.m. will be connected the next business day.

Information on this application may be used for a credit check.  Depending upon the results of your credit check, you will be required to pay a deposit in full prior to electric service being connected.

We also offer a Prepaid option.  With Prepaid there are no monthly bills or late fees.  Only $105.00 is needed to start.  Included is the $5.00 Membership Fee (refundable), $15.00 Establishment Fee (non-refundable) and $35 Deposit (refundable).  The remaining $50 is the initial prepaid advance credit applied to your account.  If you are interested in this option, please indicate "yes" in the Prepaid field area below.

NOTE: All fields with a RED (*) are required.  After clicking submit, you should get a confirmation page and confirmation email.  If you do not, then the application has not been submitted. 

Today's Date:  
Date Service is Desired:    
Type of Request:   *
First Name:   *
Last Name:   *
Middle Initial:  
Social Security #:--  *
Driver’s License #:  *
License State:  
Birth Date:    
Employer:  
Employer’s Address:  
Nearest Relative:  
Nearest Relative Address:  
Nearest Relative Phone #:  

Mailing Address:
Please enter the address where bills should be sent. Include Apt #, Suite # or Building # to line one, if applicable.
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address:
Please enter the physical, 911 address.
Service Address:  
Comments:  
E-mail:  *
Confirm E-mail:  *
Home Phone #:--   *
Cell Phone:--  
Business Phone #:--   
Spouse’s Name: 
Is there an existing meter at this location or is it new construction?
(indicate existing meter or new construction)		  *

Online Access:
As one of our services, we provide an online application for viewing and paying bills. If you would like to use this service, please specify an Internet Password and Password Hint at this time. Please note that the Internet Password must be at least four characters in length.
Password:  *
Confirm Internet Password:  
Password Hint:

Existing Service:
Have you ever had service with us before?    

Account Number:

Fee & Deposit Information:
All new applicants are required to pay a $5.00 membership fee, $15 account establishment fee, and a security deposit prior to electric service being connected. When your account is created, you will receive an e-mail with the total amount due on your new account, including the deposit amount. 

Interested in eliminating the credit check and reducing the amount of your deposit?
Our PREPAID ACCOUNT OPTION MIGHT BE RIGHT FOR YOU! CLICK HERE TO LEARN MORE!

Membership Fee:  
Establishment Fee:  

Would you like this to be a Prepaid Account?
(indicate "yes" or "no")		  *
How you would like to receive notifications of your account balance and of a pending disconnect?
(indicate "Email", "Text" and/or "Voice")		  
Please select status at service location:   *
Are you interested in Operation Round Up?   *
Please select your preferred Billing Method:   *
 
I, the above named applicant, hereby apply for electric service and agree to purchase electric energy from Cancoochee Electric Cooperative.  I have read and understand the Service Rules and Prepaid Metering Agreement (if applicable). By checking this box, I am electronically signing my application for service. I understand that a credit check will be performed on all applicants. Any past due amounts to Canoochee EMC must be paid in full before service can be established. If you’ve never had service with us before, you may be required to apply in person at one of our offices.
I understand that checking this box and typing my name in the field provided below. By signing below, you give Canoochee EMC consent to contact you via phone, send emails and SMS text alerts to inform you of account activity including account balance and usage information. If your contact information changes, it is important that you contact Canoochee to request the information be updated. Account alert and notification preferences can be managed online or via our mobile app.
  Applicant Name:     *