Please complete this form to apply for electric service. Service requests are processed during normal business hours (Mon.-Fri. 8:00 a.m. to 4:00 p.m.). If you have any questions regarding service, please feel free to contact our office during normal business hours 1-800-264-7732.

Note: All fields with the asterisk (*) are required. Incomplete applications will not be processed.

IMPORTANT:
When entering the date you would like service connected, please keep in mind that we do not connect service the same day the application is received and processed. Service will be connected the following business day or on the date requested if it happens to be a later date.  Applications received after 3 p.m., or on weekends or holidays, will be processed the following business day.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Applicant Information:
First Name:
*include suffix if applicable		   *
Last Name:   *
Middle Initial:   *
S.S. No.:--  *
Driver's Lic. No.:  *
Driver's Lic. State:   *
Date of Birth:  *  
Place of Employment:  

Mailing Address:
Please provide the address where bills should be sent.
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address:
Please provide the physical 911 address.
Service Address:  
Comments:  
E-mail:  *
Confirm E-mail:  *
Home Phone:--   *
Cell Phone:--   *
Business Phone:--   
Applicant Spouse Information:
Name:		 
S.S. No.:-- 
Driver's Lic. No.:  
Driver's Lic. State:  
Date of Birth:    
Place of Employment:  

Online Access:
We offer a portal for online bill payment and account management. If you would like access to your account online, please create a password and password hint below. Please note passwords must be a combination of letters and numbers.
Internet Password:  
Confirm Internet Password:  
Password Hint:

Existing/Previous Service:
Have you had service with us before?    
Account Number:

Membership Fee:  
Account Establishment Fee:  

Would you like this to be a Prepay Account?
(indicate yes or no)		  *
Do you rent or own at the service location?   *
Please select your preferred Billing Method:   *
 
The undersigned (hereinafter called the applicant) hereby applies for membership in Pea River Electric Cooperative, a corporation, its successors and assigns, (hereinafter called the Cooperative) and the applicant and the Cooperative agree upon to the following terms and conditions.  I also acknowledge that I have provided valid and true information on this application. The person who agrees below (hereinafter called the Applicant) hereby applies for and agrees to pre-pay purchase of energy from Pea River Electric Cooperative, Inc., a corporation, its successors and assigns (hereinafter called the Cooperative); and the applicant and Cooperative agree as follows (if applicable). I agree to receive text and email communications from The Cooperative.
I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *