The undersigned being the ______________________________________ of
(Owner, Lessee, Tenant, etc.)
the property located at _______________________________________ does hereby request electrical service at said property.

DEED of property is recorded in BOOK ____________ , PAGE ___________ and is identified as parcel ID # _________________.

SERVICE INFORMATION

Nature of Service:

( ) New Service ( ) Replacement of Service ( ) Temporary
( ) Change of Service ( ) Permanent

Classification of service:

( ) Residential ( ) Commercial ( ) Farm
( ) Industrial ( ) Mobile Home ( ) Other _______________________

Service to serve:

( ) Single Unit ( ) Multiple Unit

Service Size & Capacity:

Ø If service exists list both existing and desired size.

______ AMPS ______ VOLTS ______ PHASE ______ WIRE

______ AMPS ______ VOLTS ______ PHASE ______ WIRE

______ NUMBER OF METERS REQUESTED ______ SIZE OF MAIN PANEL

______ ANTICPATED LOAD

If Commercial Application identify:

Type of Business: ____________________________________
Size of Building: _____________________________________

Connected Loads:
Air Conditioning HP _____ _____ Motor Load HP _____ _____
Cooking Equipment HP _____ _____ Refrigeration HP _____ _____
Heating Equipment KW_____ _____ Storage Heat KW_____ _____
Lighting Load KW_____ _____ Water Heating KW_____ _____
Receptacles KW_____ _____ Miscellaneous KW_____ _____
Total Connected _______KW Estimated Demand_________KW

List all individual motors over 10 HP __________________________________________________
Miscellaneous Motors: _____________________________________________________________

Utility Construction Requested:

Ø Please include a plot plan showing property lines, proposed house site, existing ROW’s, existing power lines, and new power line locations. PLEASE INDICATE the number of feet from the proposed house site to the closest existing power location. (a simple drawing on the back of this form is sufficient)

Ø Check all that apply:

______ Underground ______ Service Loop Only

______ Overhead ______ Poles Requested ______ Wire requested (# of feet)

Will new construction cross over any other person’s property other than the property described above? ________

If YES, please list names of property owners affected: ________________________________________.

I (WE) agree to provide additional information that may be required to complete installation of the above.

I/ (WE) declare, I/WE are owners of the above described property and this application is made with my/our knowledge and consent.

Applicant Name:

Printed Name: Signature: Phone:
_________________________________ _________________________________ ___________________

_________________________________ _________________________________ ___________________

Mailing Address: Email Address: (Optional)
____________________________ ______________________________
PERSON requesting service (if other than owner):

Printed Name: Signature: Phone:
________________________________ _________________________________

Mailing Address:

___________________________

___________________________

For Office Use Only

Date Customer ready for Construction: ____________________________________________________

Date Application and Supporting Documents Received: _______________________________________

Energizing Permit: ___________________________________________________________________

Amount of Customer Advance: __________________________________________________________

Date Received: ______________________________________________________________________

Date Project Promised to be Completed: __________________________________________________

Date Project Completed: _____________________________________________________________

Comments: