Service Application

Please complete the below application to request electric service from Four County Electric Corporation. Service Requests are processed from 8 a.m. to 5 p.m. Monday through Friday. We need a minimum of 72 hours notice before service can be established. If you have any questions, or need service immediately, please contact 1-888-368-7289

Note: All fields with the asterisk (*) are required.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Customer First Name:  
Customer Last Name:  
Customer Middle Initial:  
Social Security Number:-  -   
License State:  
Birth Date:    

Please enter the address where bills should be sent:
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Please enter the street address where service is required:
Service Address:  
Service Type (Construction Required or Existing Service):   *
Meter Number:  
If applicable, directions to new construction:   *
E-mail:  *
Confirm E-mail:  *
Home Phone:-  -    *
Cell Phone:-  -   
Business Phone:-  -     *
Co Applicant Name:  *
Co Applicant SSN:-  -   
Co Applicant Driver's License:  
Co Applicant License State:  
Co Applicant Birth Date:    
Co Applicant Employer:  

As one of our services, we provide an online application for viewing and paying bills. If you'd like to use this service, you can specify an Internet Password and Password Hint at this time. Please note that the Internet Password must be at least 7 characters in length.

Internet Password:  
Confirm Internet Password:  
Password Hint:

Have you ever had service with us before?    
Account Number:

I understand that by submitting this application request, I also agree that a credit check may be submitted, if necessary, to determine if a security deposit is required.

Check here to agree to the following terms: 

By submitting this request, I, the above named individual (hereinafter called applicant) hereby apply for membership in and agree to purchase all electric energy for the requirements of the premises for which this application is made from Four County Electric Membership Corporation (hereinafter called Cooperative).The information given herein is to my knowledge correct.

The applicant for membership or the Member should bear in mind that the Membership Agreement provides that the Member will abide by all Bylaws of the Cooperative and all Policies, known as Service Rules and Regulations, adopted by the Board of Trustees of the Cooperative. Various Bylaw provisions and policies apply to many different specific problem areas. A copy of the Member Policies is available upon request.

I understand that checking this box and typing my name in the field provided below is my electronic signature. 
  Applicant Name:     *