Commercial/Business Application for ServiceDate to Begin Service(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Service Address(Required) Street Address Address Line 2 City 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 State ZIP Code Billing Address(Required) Street Address Address Line 2 City 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 State ZIP Code Organization Name(Required)Has this organization had previous/current service with Clark County REMC?(Required) Yes NoContact Name(Required) First Last Phone Number(Required)Federal Tax ID numberAttach Federal Tax ID Certificate(Required)Accepted file types: doc, docx, pdf, txt, rtf, odt, md, html, xml, tex, wpd, pages, Max. file size: 10 MB.Contact Email(Required) Is there a separate contact for Billing inquiries? Yes NoBilling Contact Name(Required) First Last Billing Contact Phone(Required)Billing Contact Email(Required) Are there any special/unique circumstances at your location? Check all that apply Solar Panels with Battery Backup Solar Panels without Battery Backup Wind Turbines Electric Vehicle Back-Up Generator None of the AboveMember 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. Electronic Signature (Full Name)(Required)
