Business/Company Name(Required) Primary Owner Name(Required) First Last Social Security Number(Required) 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 Service/911 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 Number at Business(Required)Alternate Phone NumberType of Business(Required) Federal Tax ID Number(Required) Owner's Driver's License Number(Required) Driver's License State(Required) Contact Person Name(Required) First Last Contact Person Phone(Required)Contact Person Title(Required) Name, Address, and Phone Number of Owner(s), Officers, and PartnersClick the + button to add a new rowNameAddressPhone NumberEmail Add RemoveDoes this location currently have power?(Required) Yes No Please provide the meter number (8 digits)(Required) Former Business Name If there are existing dusk to dawn lights, do you want to continue use for the monthly charge?(Required) Yes No Schedule of Membership, Deposits & Fees Membership – $5 Security Deposits Required: Commercial - Highest 2 months in 12-month operating period. If new, Engineering will estimate 2-month billing (not less than $300) Industrial – Determined by Contract Government Agency – No Deposit Churches and Schools – No Deposit Customer Charge: Small Commercial – Determined by Rate Large Commercial/Industrial – Determined by Contract Temporary Service Charge: Construction – $30 Carnivals, Revivals, etc. – Estimated Cost In and Out Meter Test – $25 Diversion of Current (add estimated usage to Diversion of Current – $150 Unauthorized Cut Seal – $150 Late Payment Penalty – 10% of Net Bill Connect/Reconnect Fee – $20 Disconnect Fee – No Fee Collection/Disconnection Trip Fee (Nonpayment) – $15 Reconnection Trip Fee (for nonpayment) Requested between 8 a.m. and 6:30 p.m. Monday through Friday – $25 Requested between 6:30 p.m. and 8 a.m. Monday through Friday – $100 Requested weekends and holidays – $100 Returned Check Charge – $30 Relocation of Service (Note: No charge if upgrade and additional load – Total CostProperty Damage Disclaimer Coosa Valley Electric Cooperative disclaims responsibility for damages incurred to driveways, septic-systems, water, systems, lawns, trees, or other obstructions while installing at consumer’s request, security lights, poles, or additional underground or aerial electric service. It is the responsibility of the consumer to, shortly after making application for service, locate any underground water, sewage, gas, and telephone service lines, septic systems, and/or any other underground hindrances on the consumer’s property. In addition, the cooperative shall have the right of ingress to and egress from the premises at reasonable times and as required, shall have the right to cut and trim trees and shrubbery to the extent necessary to keep them clear of the electric lines. The cooperative shall use all reasonable care and diligence in clearing, re-clearing, and maintenance of right-of-way and electric distribution lines.Commercial Deposits for New Electric Installation To establish the security deposit for your new business, CVEC will send out one of our engineers to estimate your monthly electric bill. Your deposit will be twice this amount. CVEC policy states that the membership and deposit must be paid in full before service will begin. Once the engineer has completed this estimate, he will inform the service department, who will then contact your company and you must pay this amount. After payment has been received, the service order will be sent out to begin work to be performed within a reasonable time period. The acceptance of this application by the Cooperative shall constitute an agreement between the Applicant and the Cooperative and the contract for electric service shall continue in force for one year from the date service is made available by the Cooperative to the Applicant and thereafter until cancelled by notice given by either party to the other at least 5 Days in advance. The applicant agrees to and hereby authorizes the Cooperative to obtain and examine the applicant’s credit and employment history through On Line Credit Services, Inc. The applicant hereby waives the benefit of the right to claim exempt from execution of any property under the Constitution and the laws of Alabama, and any other state and agrees to timely pay all charges for services rendered and upon the failure to pay all charges for services rendered, the undersigned agrees to pay all cost of collections, including a reasonable attorney’s fee and interest costs.Upload Copy of Driver's License(Required)Max. file size: 300 MB.Consent(Required)The undersigned (hereinafter called the applicant) hereby applies for membership in the Coosa Valley Electric Cooperative, Inc. (hereinafter called the Cooperative) and the Applicant and the Cooperative agree as follows: The Applicant agrees to pay the sum of $5 for membership in the Cooperative and $x as meter deposit for electric service to the Applicant’s premises. It is understood that upon termination of such service the membership fee and meter deposit, less any unpaid electric energy bills, will be refunded. Before service is initiated hereunder, Applicant will cause the premises to be served to be wired or re-wired, if necessary, in accordance with requirements and specifications of the National Electric Code (or other higher applicable standards), and agrees that all subsequent wiring of the premises will likewise be made in accordance with said codes. Applicant further, by submission of the application represents, covenants, agrees, and warrants that all wiring, original and subsequent, is or will be prior to initiation of service, in full compliance with said codes and covenants and agrees to hold the Cooperative completely and absolutely harmless from any and all liability or responsibility for any property damage or personal injury sustained by applicant or any person or entity caused by the wiring of the premises. When electric energy is made available to Applicant’s premises by the Cooperative and thereafter, Applicant will purchase from the Cooperative all electric energy used on Applicant’s premises and will pay therefore monthly for this service at the rates and upon the terms and conditions set forth in the applicable rate schedule of the Cooperative, and the same is hereby incorporated herein by this reference thereto; It being understood, however, that said rates are subject to change from time to time in accordance with the actions of the Board of Directors and the By-laws of the Cooperative. Applicant agrees to, and does hereby, grant unto the Cooperative an easement for the construction and maintenance of the Cooperative’s power lines over, on, or across any and all portions of the property adjacent thereto owned by or under control of Applicant(s). 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.Consumer Electronic Signature (Full Name)(Required) Title(Required) NameThis field is for validation purposes and should be left unchanged.