Application for Service

Please complete this application to apply for new service with Four County Electric Membership Corporation.  All new applicants are required to pay a connect fee before service is connected.  If applicable, a credit check may also be necessary to detemine if a security deposit is required.      

If you have any questions regarding setting up service, please feel free to contact our office at (910) 259-2361 (Burgraw), (910) 862-3551 (Elizabethtown) or (910) 289-4534 (Rose Hill).

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

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Applicant First Name:   *
Applicant Last Name:   *
SSN:-  -   *
Driver's License #:  *
License State:  
Birth Date:    

Billing Address
Please enter the address where bills should be sent:

Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address
Please enter the street address where service is required:

Service Address:  
Service Type (Construction Required or Existing Service):   *
If applicable, directions to new construction:  
E-mail:  *
Confirm E-mail:  *
Home Phone:-  -    *
Cell Phone:-  -    *
Work Phone:-  -     
Co Applicant Name: 
Co Applicant SSN:-  -   
Co Applicant Driver's License:  
Co Applicant License State:  
Co Applicant Birth Date:    
Co Applicant Employer:  

Billing Address

As one of our services, we provide an online application for viewing and paying bills. If you are interested in using this service, please specify an Internet Password and Password Hint at this time. For security purposes, please create an Internet Password that is at least 4 characters in length.

Internet Password:  
Confirm Internet Password:  
Password Hint:

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

Do you Own or Rent this location?  
Please select preferred Billing Method:   *
I understand the terms and conditions outlined in the Member Handbook. 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.