Business Name(Required) Applicant Name(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Business Phone(Required)Business FaxCell Phone(Required)Consent(Required)The undersigned (hereinafter called the Applicant) hereby applies for membership in, and agrees to purchase electric energy from the Wayne White Counties Electric Cooperative (hereinafter called the Cooperative) upon the following terms and conditions: This application shall entitle Applicant to membership in the Cooperative upon approval by its Board of Directors and receipt of electric service. A membership is held jointly by husband and wife, by partners in a partnership, or other persons desiring a joint membership. This Applicant will, when electric energy becomes available, purchase from the Cooperative all electric energy used on the premises, or as Board policies allow, and will provide, without cost to Cooperative, all easements necessary for the construction, operation, repair, replacement, improvement, and maintenance of electric lines and service to and on such premises in accordance with the Cooperative’s policies, and agrees to pay therefore monthly at rates determined from time to time in accordance with the Bylaws and operating polices of the Cooperative. The Cooperative reserves the right to limit the amount of electric energy to be furnished to the Applicant. The Applicant will comply with and be bound by the provisions of the certificate of the incorporation and Bylaws of the Cooperative, and such rules, regulations, and policies as may from time to time be adopted by the Cooperative. A copy of the member policies and bylaws are available upon request at the cooperative office, or they can be viewed on our cooperative website. The Applicant agrees that all electric energy becomes the property of the Applicant after it passes the metering equipment, and the Cooperative shall not be liable for damages resulting there from and thereafter, except where such loss or damage results from negligence of the Cooperative. The undersigned hereby agrees that in the event suit is filed, for the collection of any unpaid electric bills, in any court of competent jurisdiction, reasonable attorney fees and cost shall be added to the balance due for electric service rendered. Unless otherwise provided in a separate agreement for electric service between the Applicant and the Cooperative, the acceptance of this application by the Cooperative shall constitute a contract for the electric service between the Applicant and the Cooperative which shall begin from the date service is made available to the Applicant and shall continue thereafter until cancelled by at least 30 days written notice by either party to the other. Any misinformation will void this contract & make the account subject to immediate disconnection. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Applicant Electronic Signature (Full Name)(Required) NameThis field is for validation purposes and should be left unchanged.
