"*" indicates required fields Service Type* Turn On Electric Disconnect Electric Service New Construction Fiber Services (Long Island Project) Fiber Services Only (Choose this option if you already have electric services with us.) Account Number*Name* First Middle Initial Last Name* First Last Address 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 Address* Phone Number*Alternate PhoneDriver License Number*Driver License State* 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 Upload scan or photo of driver license*Accepted file types: doc, docx, pdf, jpg, jpeg, gif, tiff, png, Max. file size: 100 MB.Max. file size: 128 MB. Date of Birth* Month Day Year Social Security Number*Phone Number*Service Address* 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 Mailing Address (if different) 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 Employer*Employer Phone Number*Add a co-applicant?* Yes No Co-applicant Name* First Last Co-applicant Social Security Number*Co-applicant Date of Birth* MM slash DD slash YYYY Co-applicants State and Driver License Number*List the names of any adults over the age of 18 years old living in household:* Add RemoveHave you ever had service with North Alabama Electric Cooperative?* Yes No Previous Service Address* 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 Renting or purchasing? Renting Purchasing Residence Type:* House Mobile Home Other Will this be your primary residence?* Yes No What type of service will this new construction require?* Underground Overhead Additional Notes:Date to be turned off (mm/dd/yyyy)* Month Day Year Apply or Hold Membership and Deposit* Apply Hold Forwarding Address* 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 Phone**If you are renting or leasing you will need to fax or email rental/or lease agreement with Landlords name, address, and contact phone number, along with a copy of your picture identification. If you are purchasing a property, we will need the warranty deed or purchase agreement along with a copy of your driver’s license. **If you are renting and want to add our Fiber Services you will need permission from your Landlord in the form of a letter.Upload rental or purchase agreement*Accepted file types: doc, docx, rtf, txt, odt, pdf, jpg, jpeg, gif, tiff, png, Max. file size: 100 MB. Drop files here or Select files Max. file size: 128 MB. Upload a photo of Sand Mountain Electric Cooperative meter*Accepted file types: doc, docx, rtf, txt, odt, pdf, jpg, jpeg, gif, tiff, png, Max. file size: 100 MB. Drop files here or Select files Max. file size: 128 MB. Do you agree to the following terms and do you consent to sign this form electronically?* Yes Electronic Signature (Full Name)*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 North Alabama Electric Cooperative (hereinafter called Cooperative). The information given herein is to my knowledge correct. A soft credit check will be performed to determine the amount of your deposit, and we will contact you with the amount due. Once the membership and deposit has been paid by use of kiosk, online, night drop, or over the phone an order to connect your services will be generated. Once the order has been submitted, it will be connected the next business day if possible. By submitting this request, I, the above named individual (hereinafter called applicant) hereby agree that the information given herein is to my knowledge correct.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 North Alabama Electric Cooperative (hereinafter called Cooperative). The information given herein is to my knowledge correct. A soft credit check will be performed to determine the amount of your deposit, and we will contact you with the amount due. Once the membership and deposit has been paid by use of kiosk, online, night drop, or over the phone an order to connect your services will be generated. Once the order has been submitted, it will be connected the next business day if possible.By submitting this request, I, the above named individual (hereinafter called applicant) hereby agree that the information given herein is to my knowledge correct. Bylaws Click here to download a copy of our Bylaws.I verify that I have read the bylaws linked above.* Yes
