Application for Residential Service

Application for Residential Service

A security deposit may be required at time application is completed, as well as copy of driver's license and lease/proof of ownership.
Name

First NameMiddle NameLast Name
Home Phone No.
Cell Phone No.
What other names have you used?
Name

First NameLast Name
Social Security Number
Social Security Number
Example: xxxxxxxxx
State I.D. or Driver's License Number
State I.D. or Driver's License Number
Census Number (if applicable)
Census Number (if applicable)
Spouse or Second Party's Name
Spouse or Second Party's Name

First NameLast Name
Social Security Number
Spouse or Second Party's Social Security Number
Mailing Address

Mailing Address

Street Address Line 2

CityState

Zip Code
Email Address
Continental Divide will send you an electronic opt-in/out form for co-op related communications.
Email
example@example.com
Employer
Employer Mailing Address
Work Phone Number
Physical Address of Location to be Connected
Physical Address of Location to be Connected

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Number or Previous Tenant
Do you

OwnRentLeaseProcess of buying
Structure Type

HouseApartmentManufactured/Mobile HomeWellOther
Color of Structure
Color of Roof
Directions for Rural Service: (Rural Address, Description, Lot, Block and Unit)
(Rural Address, Description, Lot, Block and Unit)
To process your application, we will need a copy of your Driver's License and a copy of your lease or proof of ownership of the property where you are requesting service.*

Upload files here.
Cancelof
To take a screenshot of the documents requested above, click on the Take Photo box.
The undersigned hereby acknowledges request for electrical service as stated on this form and assumes full responsibility for prompt payment of billings as they become due and collection fees, if any. A copy of the bylaws, terms and conditions of service have been received.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: