Residential Customer Sign Up Form

Please fill out the Sign-Up form completely!

Form Information

Please fill out the bottom fields completely. Once you are done, we will contact you for final signatures as soon as possible. If you have any questions, please contact us! Have a great day!

DISCLAIMER: If there is a penalty for early termination from you current electricity provider, it will be up to the client to pay the termination fee. If you need help determining if you are still under contract with your current electricity provider, please email us a copy of your latest bill to INSERT EMAIL HERE with the title “Am I Still Under Contract?”

Name

First Name

Last Name

Who referred you? (Optional)

Name of Reference (Optional)

First Name

Last Name

Service Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Billing Address (If Different than Service Address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Phone

(###)

###

####

Social Security

Contract Length & Start Date

Preferred Length of Contract

Account Info

What kind of sign up are you making today?

Changing from another provider

Moving to a new location that does not have service

Preferred Start Date

YYYY

Auto Pay Selection

Auto-Pay

Yes

If Yes, please fill out the information below.

Cardholder's Name

Please fill this out if you are using a credit card for auto pay.

First Name

Last Name

Credit Card Company

Card Number

Expiration Date

Security Code

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please fill out the information below if you will be using a bank account for auto pay

Bank Name

Name on Account

First Name

Last Name

Account Number

Routing Number