South Alabama Electric Cooperative

Application for Membership and Service Agreement

* Indicates required field

By submitting this application electronically, the applicant hereby applies for electric service to be provided by the Cooperative and authorizes the Cooperative to perform a credit check to determine credit-worthiness and establish positive identification. The Cooperative will require a copy of your rental/lease agreement or a purchase agreement. Furthermore, the applicant agrees to pay the applicable connect fees, security deposits based on credit score and be bound by all provisions in the Cooperative's Bylaws and Service Rules and Regulations, along with all applicable laws, rules, regulations, statutes, and ordinances as they may now exist and as they may be modified from time to time.

Any information obtained in connection with the Membership Application and Service Agreement will be used by the Cooperative for credit purposes only and no information received will be distributed to any third party except in an effort to collect upon the account.

Please complete and summit the following application information. A customer service representative will contact you within 24 hours to complete your application.

General Information

* First Name

* Last Name

* SSN:

SSN2

SSN3

* Date Of Birth

DAY

YEAR

Driver's License

* Drivers License State

* Drivers License No:

Mailing and Service Addresses

* Current Mailing Address:

* City:

* State:

* Zip:

* Phone:

PHONE2

PHONE3

* Email:

* Service is requested at:

* City:

* State:

* Zip:

Spouse/Co-Applicant Information

First Name:

Last Name:

SSN:

SSN2a

SSN3a

Date Of Birth

dob2

dob3

* I am the primary tenant/resident at the above listed address:

Yes

Names of other adults living in the household:

I also attest to the fact that the previous tenant/resident no longer resides at this address. I understand that making false statements when applying for utility service is a violation of state law and that it may be punishable by a fine and /or jail term. I attest that I have reviewed all the information above and verified that it is correct.

Service Connection Date

* What date would you like the service connected?

(mm/dd/yyyy format)

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