Residential ApplicationLinkedInThis field is for validation purposes and should be left unchanged.Date to Begin Service(Required)Once all paperwork and payments have been received, it may take up to three (3) business days for service to be connected. Name(Required) First Middle (If no middle initial, enter 1234) Last 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 Billing 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 Phone(Required)Email(Required) Email Confirm Email Preferred Contact Method(Required) Email PhoneAre there any special/unique circumstances at your location? Check all that apply.(Required) Solar Panels with Battery Backup Solar Panels without Battery Backup Wind Turbines Electric Vehicle Back-Up Generator None of the AboveEV Year, Make and Model(Required)ie, 2022 Ford Mustang Mach-EDo you have a home EV Charger?(Required) No, we charge at retail and other public stations. Yes, level 1 (trickle charge with a standard 120V household outlet and cord) Yes, level 2 (faster charge with a dedicated 240V outlet)Would you like information on a special whole-home rate for electric vehicle charging?(Required) Yes NoTo receive credit for solar generation at your property, you must first complete and sign an Interconnection Agreement and provide REMC with proof of homeowner’s insurance. Until all required documentation is received and approved, your account will remain on the standard residential rate, and no credit for generation will be applied.Is this request for an existing building or new construction?(Required) Existing Building New ConstructionDate of Birth(Required) Month Day Year Providing your social security number allows Clark County REMC to run a soft-hit credit check during the application process. This information will be used to determine if a security deposit is required.(Required) I will provide my social security number I will not provide my social security number. I understand that I will be required to pay a depositSocial Security NumberProviding your social security number allows Clark County REMC to run a soft-hit credit check during the application process. This information will be used to determine if a security deposit is required.Billing Type(Required)Please select which service type you are applying for Traditional Monthly Billing (may require security deposit) Prepaid Billing (no security deposit required) I'm not sureWhat other service and account features are you interested in?(Required) Budget Billing Auto-Pay Time-Of-Use Rate Electric Vehicle Rate Nothing at this timeHave you had previous service with Clark County REMC?(Required) Yes NoPrevious 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 Member Consent and Agreement(Required) 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.The undersigned (hereinafter called Applicant) hereby applies for membership in and agrees to purchase all electric energy and distribution services from the CLARK COUNTY RURAL ELECTRIC MEMBERSHIP CORPORATION (hereinafter called Cooperative).The Applicant agrees to provide any easement or right-of-way necessary at no cost to the Cooperative for the Cooperative to provide service.The Applicant agrees to comply with the Bylaws of the Cooperative and any amendments thereto, and such Rules and Regulation as may be adopted from time to time.The Applicant agrees to pay for services rendered and/or the minimum bill in accordance with the applicable rate schedule and the Cooperative policy.The Applicant acknowledges and agrees that if REMC must initiate collection efforts to recover amounts owed to REMC by the applicant, then in addition to amounts incurred for the services rendered and/or the minimum bill the applicant will pay: (a) any and all costs incurred by REMC in pursuing collection, including, but not limited to, reasonable attorneys’ fees, and (b) any court costs, any other costs of litigation as are permitted by applicable law, pre-judgment interest as permitted by law, post-judgment interest, and collection fees incurred by REMC to the fullest extent permitted by law.The Applicant agrees to pay for construction charges, when deemed necessary, according to the Cooperative policy.The Applicant shall provide credit information prior to rendering of electric service. The Cooperative may require a cash security deposit in accordance to Cooperative policy. Such deposits may bear interest in accordance to Cooperative policy. Any portion of said deposit not applied to the payment of bills due the Cooperative shall be refunded to the Applicant upon termination of service.The Applicant shall provide the Cooperative the right of access to the premises for the purpose of installing, reading, inspecting or repairing electric meters or other equipment for any purpose incidental to providing electric service.The acceptance of this application by the Cooperative shall:Commence on the date that service was made available by the Cooperative, and continue thereafter until cancelled by written or oral notice given by the customer to the Cooperative or by disconnection of the Applicant’s service by the Cooperative.Constitute a contract for electric service between the Applicant and the Cooperative which shall continue in force until cancelled by termination of services or at least ten days written notice by either party to the other.Constitute an acceptance of the Applicant to membership in the Cooperative with such rights and liability as are specified in the By-laws of the Cooperative.Applicant, by becoming a member, assumes no personal liability of responsibility for any debts or liabilities of Cooperative, and is expressly understood that under law his private property cannot be attached for any such debts or liabilities.Applicant consents to receiving autodialed and prerecorded message calls to the extent that such calls and messages are closely related to the service purchased from the Cooperative. Examples of such calls include, but may not be limited to, those that warn about planned or unplanned service outages; warn about extreme weather conditions approaching that might cause outages; alert the Applicant about utility repair work in the immediate vicinity of the location where service is provided to the Applicant; provide updates about service outages or service restoration; ask for confirmation of service restoration or information about lack of service; provide notification of meter work, tree trimming, or other field work that directly affects the Applicant’s utility service; and calls that provide information about potential brown-outs due to heavy energy usage.Applicant shall inform the Cooperative whenever there is a change in any of Applicant’s telephone number(s) (whether wireless or non-wireless) and other contact information. By electronically signing this document, I am acknowledging the following: (a) the accuracy of the information provided above; (b) that by signing here and disclosing my mobile telephone number I agree that REMC, its agents and its contractors can call me on that number using an automatic telephone dialer and/or that REMC, its agents and its contractors can leave a pre-recorded and/or text message on that number; and (c) that I accept responsibility for this account. I understand that any member who knowingly engages in deceit or makes a false, misleading or inaccurate statement to the REMC shall be held accountable for all losses and/or costs incurred by Clark County REMC. I understand that no member owing an electric bill or who has been disconnected due to an unpaid electric bill may receive electricity by establishing an account in any other name, unless and until the past due amount and associated fees and costs are paid in full. Prepaid Agreement(Required) 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. Prepaid Electric Service (PES) from Clark County REMC is available to any residential class member as an optional rate provided the following criteria are met: A. Eligibility 1. New – Anyone applying for new service may choose PES regardless of payment history or credit rating. • Application fee of $25 must be paid up front. • A $50 Prepaid Credit Balance is required upon enrollment. 2. Existing – An existing member may choose PES at any time. • A $50 Prepaid Credit Balance is required upon enrollment. • Any past due balance must be paid prior to enrollment in the program. • Any current balance and/or unbilled usage may be converted to a Prepaid Arrangement. • Fifty percent of any future payments made on the account will go toward paying the Prepaid Arrangement with the remaining 50% applied to the Prepaid Balance. Once the Prepaid Arrangement is paid, 100% of any future payments will go towards the Prepaid Balance. • If an account is disconnected for non-payment, the member may apply for PES at the time of reconnection. In addition to the conditions above, the member must also pay a $50 reconnect fee. B. Requirements/Terms/Conditions 1. To enroll in PES, no deposit is required. 2. Member must have, upon enrollment, a $50.00 Prepaid Credit Balance. 3. After enrollment, the minimum payment amount toward PES is $10.00. 4. Any existing security deposit on file with the REMC will be applied to the account balance and, if applicable toward future PES. 5. Energy Assistance or other types of assistance will be applied to the Prepaid Balance when the pledge is received. 6. Electric service will be subject to disconnection at any time the Prepaid Balance falls below zero. If service is disconnected, a minimum Prepaid Credit Balance of $10 is required before service is restored. 7. PES members will not receive a paper bill. 8. Auto draft payment is not available for PES. 9. Budget billing is not available for PES. 10. PES accounts are not eligible for payment arrangements. 11. Medical conditions will not postpone disconnection. 12. If a returned check or electronic chargeback is received on a PES account, the amount of the return and a return fee of $25 will be charged to the member’s account immediately. If this causes the Prepaid Balance on the account to fall below zero, service may be disconnected within 24 hours. 13. If at any time, a Prepaid member wants to convert to a General Service account, a deposit may be required based on a two-month average bill for that location. The decision to charge a security deposit will be based on existing credit reporting. 14. Payments for PES may be made in the office, by mail, by phone, or online at clarkremc.smarthub.coop. The REMC is not responsible for any delay in payment processing. 15. Clark County REMC reserves the right to refuse to furnish service to a member at any new location until all delinquent bills of such member for services in any previous location(s) served by the REMC are paid. 16. It’s the member’s responsibility to notify the REMC office to request termination of service when moving or vacating the property. 17. At the time service is terminated, the member will receive refund of any remaining credit on the account. If service is disconnected and remains off for 10 days, the account will be closed. Any fees associated with reconnecting the service will be charged when reconnected. C. Fraudulent Use of Electricity 1. Clark County REMC will not tolerate meter tampering of any kind. Theft by deception will also not be tolerated. Service will be disconnected without notice. Meter tampering fees will be assessed to the account. I understand that by signing this Prepaid Electric Service (PES) Agreement, I am agreeing to abide by the terms listed above. Member Electronic Signature (Full Name)(Required)Would you like to add a second applicant to your account?(Required)Additional applicants are able to make payments, receive account information, and make changes to the account. Yes NoIs this additional applicant your spouse?(Required) Yes NoAdditional Contact Name(Required) First Middle (If no middle initial, enter 1234) Last Additional Contact Phone(Required)Additional Contact Email(Required) Email Confirm Email Additional Contact Preferred Method(Required) Email PhoneAdditional Contact Date of Birth(Required) Month Day Year Providing your social security number allows Clark County REMC to run a soft-hit credit check during the application process. This information will be used to determine if a security deposit is required.(Required) I will provide my social security number I will not provide my social security number. I understand that I will be required to pay a depositAdditional Contact Social Security NumberProviding your social security number allows Clark County REMC to run a soft-hit credit check during the application process. This information will be used to determine if a security deposit is required.Untitled
