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Customer Information

*NOTE* A non-refundable $100 Application Fee is required and the Residential Electrified Services Application Requirements on this form must be met before your application can be processed.

Name(Required)

First Last

Social Security Number(Required)

Date of Birth(Required)

Phone(Required)

Email(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Builder/Electrical Contractor (Contact Person)

Optional, but preferred

Phone

Site Information

Service Address(Required)

Street Address Address Line 2 City ZIP Code

Subdivision Name

Parcel/Lot No(s).(Required)

Detailed Directions to Site

Nearest Cross Street

Load Information

Service Type(Required)

House

Manufactured Home

R.V.

Shop

Other

Other Service Type(Required)

No. of Panels(Required)

Size of Panels(Required)

Mounted on(Required)

House

Shop

Well House

Post

Do you already have an EV Charger?(Required)

Yes

House Information

House Size(Required)

Shop Information

Shop Size(Required)

No. of Panels(Required)

Size of Panels(Required)

Service Entrance

Service Entrance Size(Required)

Type

Self-Contained

Current Transformer

Type of Heat & Load in KW

Type of Heat(Required)

Electrical

Gas

Propane

Other

Other Type of Heat(Required)

Do you have a heat pump?(Required)

Yes

Heat Pump Ton 1(Required)

LRA 1(Required)

Auxiliary Heat 1(Required)

Heat Pump Ton 2

LRA 2

Auxiliary Heat 2

Electric Furnace

Wall Heat

Baseboard

Additional Loads

Water Heater(Required)

Electric

Gas

N/A

Cooking(Required)

Electric

Gas

N/A

Dryer(Required)

Electric

Gas

N/A

Well(Required)

Yes

Well KW(Required)

Hot Tub(Required)

Yes

Hot Tub KW(Required)

Welder(Required)

Yes

Welder KW(Required)

E/V Charger(Required)

Yes

E/V Charger KW(Required)

Other Additional Load

Other KW

Additional Information

Temporary Service(Required)

Yes - Underground

Yes - Overhead

Temporary Size

Note: Temporary service will be disconnected upon connection of permanent service unless otherwise requested. (12 month max)

Additional Remarks including any future load requirements:

Residential Electric Service Application Requirements

Option 1:

Service address obtained from the local government agency and posted at the site.

Electric heat load(s) include: heat pump tonnage (Ton), locked rotor amps (LRA), kilowats (KW) of auxiliary heat strips.

Road/driveway installed and capable of supporting heavy trucks.

House perimeter staked and the planned meter base location marked.

Copy of your assessor's map and/or survey, or short plat, and property corners identified in the field.

Copy of your title report, recorded warrenty deed, or real estate contract.

Site plan including: all buildings, well, septic system, retaining walls, fences, and landscaping

Acknowledgement of Requirements(Required)
I acknowledge and understand that I need to meet the above requirements and am required to submit the above documents.
Directions on how to submit documents will be sent to you in your confirmation email.

Option 2:

I have:(Required)
A service address obtained from the local government agency and posted at the site

I understand:(Required)
Electric heat load(s) include: heat pump tonnage (Ton), locked rotor amps (LRA), kilowatts (KW) of auxiliary heat strips

I have:(Required)
A road/driveway installed and capable of supporting heavy trucks

Note: any deviation from the electrical design, once established may result in incurring additional costs for redesign and construction may be delayed. It is the customer's responsibility to provide all the necessary PUD requirements and specifications to subcontractors.

I affirm that the above information is correct to the best of my knowledge. I have met all of the above Residential Electrical Service Application Requirements.

Electronic Signature(Required)

Date(Required)
Month
Day
Year