Residential Service Application

MEMBER INFORMATION

Member's Name

First Middle Initial Last

Date Of Birth

Email Address

Home Phone #

Cell Phone #

Place of Employment

Employers Phone #

Previous Mailing Address

Street Address Address Line 2 City State ZIP Code

SPOUSE/OTHER RESPONSIBLE PARTY

Name

First Middle Initial Last

Date Of Birth

Email Address

Home Phone #

Cell Phone #

Place of Employment

Employers Phone #

I hereby request electric service from the Fulton County Rural Electric Membership Corporation and herewith make application for membership in this cooperative. I agree to purchase all electric energy used on my premises covered under this application, and agree to be bound by the Articles of incorporation, the By-Laws and amendments thereto, and such rules and regulations as may be adopted from time to time by the Board of Directors.

EMERGENCY CONTACT

Contact Name

Relationship

Address

Phone #

SERVICE INFORMATION

Property Meter is Serving:

Home - Own
Home - Rent
Barn w/Living Area
Barn
Garage
Campsite
Grain Bins
Irrigation
Other

If other, please list:

Have you ever had service with Fulton County REMC?

Yes
No

If yes, under what name were you billed?

By signing below, I hereby state that all the above information is true and correct.

Signature

Date

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Email

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APPLICATION FOR MEMBERSHIP & SERVICE

MEMBER INFORMATION

SPOUSE/OTHER RESPONSIBLE PARTY

EMERGENCY CONTACT

SERVICE INFORMATION