Transfer Request Date (mm/dd/yyyy)(Required) Month Day Year Type of Service(Required) Existing Structure House Existing Structure Mobile Home Existing Structure Rental House New Construction Service 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 Upload proof of ownership(Required)Please provide a full lease in its entirety (including the signed pages), a copy of the deed, or a copy of your closing statementMax. file size: 350 MB.Marital Status Single Married Divorced Separated Widowed Account Type Options(Required) Joint (only if married) Single Name(Required) First Middle Last Email(Required) Home Phone NumberCell Phone Number(Required)Driver's License(Required)Max. file size: 350 MB.Social Security Number(Required) Employer Name(Required) Employer 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 Employer Phone NumberHiddenSocial Security Number OLD(Required)Spouse Full Name First Middle Last Spouse Phone NumberSpouse Driver's LicenseMax. file size: 350 MB.Spouse Social Security Number Spouse Email(Required) Spouse Employer Name(Required) Spouse Employer 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 Spouse Employer Phone NumberEmergency Contact (not living with you) First Last Emergency Contact Phone NumberIs there currently an outdoor light on the property?(Required) Yes No Would you like it connected for $30 plus a monthly maintenance fee?(Required) Yes No Name of the nearest neighbor? First Last Billing Address (if not same as Mailing) 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 Cooperative Living Magazine Digital SubscriptionEffective August 16, 1977 as per action of the Board of Directors, each applicant requesting service from Community Electric Cooperative desiring to receive the publication “Cooperative Living” will sign the following request as required by the Post Office for the mailing of this class of mail. The subscription shall be paid for each member by the Cooperative from any funds accruing in each member’s favor so as to reduce such funds in the same manner as would any other expense of the Cooperative. Subscribe Please enroll me in only receiving the digital copy of Cooperative Living Magazine. Proxy CardName of Member Giving Proxy(Required) First Last Name of Joint Member Giving Proxy(Required) First Last Wheras, the Community Electric Cooperative, a Virginia Corporation, functions through its members and it is desirable to have all members or a large percentage of them present at annual and special meetings, or to have them properly represented so that the Cooperative will be in a position to act, and transact its necessary business, therefore, in consideration of membership in Community Electric Cooperative, Windsor Virginia, and the desire of the undersigned to be represented at meetings of members of said Cooperative, the undersigned hereby appoints: (Required) A member of corporation in good standing The proxy committee as may be duly appointed from time to time by the Board of Directors of said Cooperative as his/ her or its proxy Name of Proxy To vote and act for the undersigned member at any regular or special meeting of the members of the said Cooperative at which the undersigned is not personally present. It is understood that the undersigned will vote in person when present, and that this proxy may be revoked at any time by notice in writing or request in person to the Cooperative, but this proxy shall remain in force from year to year until so revoked.Electronic Signature of Member Giving Proxy (Full Name)(Required) Electronic Signature of Joint Member Giving Proxy (Full Name)(Required) AgreementConsent(Required) By signing this agreement, I understand that I am joining Community Electric Cooperative, and that as a member of the cooperative I have certain rights and responsibilities. The rights include voting on bylaw changes and the Board of Trustees. The responsibilities include following the policies and bylaws of the cooperative, which can be found on the cooperative’s web-site I agree to pay for my services in a timely manner, and understand that failure to pay will result in having my services terminated. In the event that my services are terminated, additional fees and deposits may be required to have my services restored. I agree to grant the cooperative an easement for power lines for my service, as well as for additional services that might be located near to my service. In addition, I agree to allow cooperative employees and agents to come upon my property to maintain and restore services. Part of that maintenance may include the cutting or spraying of bushes, shrubs and trees that may interfere with power lines. I /We agree, in order for Community Electric to service my/our account or to collect monies I/we may owe, Community Electric Cooperative, and/or its agents may contact me/us by telephone at any telephone number associated with my/our account, including wireless telephone numbers, which could result in charges to me/us. Community may also contact me/us by sending text messages or emails, using any email address I/we provide to community. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable. I/We have read this disclosure and agree that Community Electric Cooperative, Inc., its employees and/or agents may contact me/us as described above. If you pay toward construction, the money you pay is a contribution- you are not purchasing the poles and lines for yourself, and therefore, you have no ownership rights in them; They are all owned and maintained by community electric. Therefore, if, in the future, other members desire to make a connection to the poles or wires for which you contributed toward the installation, you cannot prevent them from doing so, as you have no ownership rights in them, other than those same rights afforded to every Community Electric member. I hereby acknowledge and attest that all of the information that I have provided on this application is true and correct to the best of my knowledge. By signing below, I attest that I am authorized to execute this application on behalf of the applicant and have read and understand this application and its attachments. 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.Electronic Signature (Main Applicant Full Name)(Required) NameThis field is for validation purposes and should be left unchanged.
