Date Service Requested (mm/dd/yyyy)(Required) Month Day Year Service 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 Property Status(Required) Own Home Rent Landlord Business Name (if applicable) EIN Number (if applicable) Is the mailing address the same as the service address?(Required) Yes No Mailing Address 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 Applicant's Name(Required) First Last Social Security Number(Required) Date of Birth (mm/dd/yyyy)(Required) Month Day Year Driver's License NumberState(Required) 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 State Phone(Required)Email(Required) Employer We require a valid ID. We accept several forms of identification as listed below. One of the primary IDs must be a photo ID.PRIMARYValid US Driver’s License | Gun Carry Permit | Passport or Passport Card | Military Identification | Green Card | Consular ID Card | US Employment Authorization Card | Permanent Resident Card | State Issued Identification | SECONDARYBirth Certificate | Social Security Card | Insurance Card | Voter Registration Card | Property Tax Receipt | Posted Mail with Applicant's Name | Utility Bill | Lease Agreement or Mortgage Statement | College Enrollment Papers | Vehicle Registration | Upload Two Forms of ID(Required)Please take pictures and upload two forms of ID below. Drop files here or Select files Max. file size: 300 MB, Max. files: 5. Marital Status(Required) Single Married Spouse's Name(Required) First Last Social Security Number(Required) Driver's License NumberState(Required) 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 State Date of Birth (mm/dd/yyyy)(Required) Month Day Year PhoneEmployer Email Certificate of Membership I, (hereinafter called "applicant") hereby apply for membership in and agree to purchase electric energy from Appalachian Electric Cooperative, Jefferson City, Tennessee, (hereinafter call "Cooperative") to be supplied at any address served by said Cooperative. The applicant agrees to pay for said services as bills are rendered therefore, in accordance with the By-Laws of the Cooperative. Rules and Regulations as may be adopted from time to time by the Cooperative, and rates in effect at the time of the delivery of service. The applicant agrees, when electric service becomes available, that all electric energy used on the premises will be purchased from the Cooperative and will be paid for at rates currently in effect or as amended from time to time provided, however, that the Cooperative may limit the consumption of electric energy which it shall be required to furnish the applicant. The applicant agrees that a bill of the amount listed below will be paid regardless of the number of kilowatt hours consumed and that this instrument must be considered as a agreement when this section is completed. The applicant agrees to (a) make payment of such membership fee as required by the Cooperative By-Laws, their amendments, and/or Rules and Regulations in respect to said membership; (b) make such deposits with the Cooperative as may be required by the Cooperative's Rules and Regulations. The acceptance of this application by the Cooperative shall constitute an agreement between the applicant and Cooperative and the contract for electric service shall continue in force until cancelled by either party in accordance with the By-Laws and Rules and Regulations of the Cooperative. The applicant, by becoming a member, assumes no personal liability or responsibility for debts or liabilities of Cooperative and it is expressly understood that, under law, his private property cannot be attached for any such debts or liabilitiesTerms of Membership(Required) This membership and all rights and privileges thereto shall begin upon applicants acceptance as a member by the Cooperative Board of Directors and continue as long as (a) the member purchases electric energy from the service connection designed in said person's application for membership; and (b) complies with the terms and conditions in respect to membership contained in the By-Laws of the Cooperative and any amendments thereto and such Rules and Regulations as are adopted from time to time by the Board of Directors. This membership is not transferrable. Obligations accruing to the cooperative are the responsibility of the within named member. 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.Applicant's Electronic Signature (Full Name)(Required) All information submitted in this form has AES-256 encryption to protect your personal information.CommentsThis field is for validation purposes and should be left unchanged.