Electric Service Request2 – Cimarron Electric Cooperative

New Service Residential Form

Primary Applicant Information

First Name*

Last Name*

Mailing Address*

City | State*

Zip Code*

Primary Phone*

Secondary Phone

Email address*

Date of Birth

Social Security Number

Driver's License or Formal ID Number & Issuing State

Current Employer

Employer's Phone Number

Employer's Mailing Address

City | State

Zip Code

Is there a secondary applicant?

Secondary Applicant Information

First Name

Last Name

Mailing Address

City | State

Zip Code

Cell Phone

Home Phone Number

Email address

Date

Social Security

Driver's License or Formal ID Number | State

Current Employer

Employer's Phone Number

Employer's Mailing Address

City | State

Zip Code

Service Location Information

Type of service you are requesting:

Have you spoke with an electrician to determine size of service needed?

Will this be Overhead or Underground service?

Did the location previously have electrical service?

Are you the home owner?*

Yes

Renting

New Service Street Address, 911 Address, GPS or Legal Description*

Will this service be in a housing addition?

Please Enter Housing Addition, Block and Lot (if known)

The Undersigned has authorized Cimarron Electric Cooperative to obtain a credit history for evaluating credit performance in connection with this application.

Name*

Date*

Please type the characters*

This helps us prevent spam, thank you.

This field should be left blank

New Service Residential Form

The Undersigned has authorized Cimarron Electric Cooperative to obtain a credit history for evaluating credit performance in connection with this application.

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