APPLICATION FOR MEMBERSHIP

(Please note that a credit check will be performed on all applicants)

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 will 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 an attractive Prepaid account.  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.
Care of Address:  
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: 
Spouse’s SSN:-  -   
Co Applicant Driver's License:  
Co Applicant License State:  
Co Applicant Birth Date:    
Co Applicant Employer:  

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. 


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 is my electronic signature.
  Applicant Name:     *