Service Application

To apply for residential or commercial service with Amicalola Electric Membership Corporation, please complete the application below.  If you have any questions regarding new service please send an email to memberservice@amicalolaemc.com.  

Note: All fields with the asterisk (*) are required.


Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Applicant Information:
Legal First Name:		   *
Legal Last Name:   *
S.S. #:--  *
Driver’s License #:  *
License State:  
Birth Date:    
Employer:  
Federal ID #:  
Type of Structure:
(House, Apt, Duplex, Mobile Home, Shop, Garage, Barn, Outbuilding, Other)		  *
Is the structure already constructed or on the property? (yes or no)  *
Do you need Temp to build service? (yes or no)  *
County of Service Location:
(Bartow, Cherokee, Dawson, Fannin, Forsyth, Gilmer, Gordon, Lumpkin, Murray, Pickens)		  *

Billing Address:
Please enter the address where bills should be sent:
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address:
Address where service is to be connected:
Service Address:   *
Directions to Property:   *
E-mail:  *
Confirm E-mail:  *
Home Phone:--   *
Cell Phone:--   *
Spouse Information:
Name:		 
S.S. #:-- 
Driver's License #:  
License State:  
Birth Date:    
Employer:  
Employer Phone:  
Emergency Contact:
Name:		  *
Contact Phone:  *

Membership Fee:  
Processing Fee:  

If renting. Owners Name:  
If renting. Owners Phone Number:  
Do you rent or own the service location?   *
Participate in Operation Round Up?   *
Please select preferred Billing Method:   *
 
By checking this box, Applicant agrees to the following:
  • Applicant acknowledges that at the time he/she signed this application he/she received a copy of the Bylaws, Rules and Regulations and the Statement of Nondiscrimination. Furthermore, applicant has read, understands and agrees to the Contract for Power Line Installation.
  • Applicant consents to email notification of any Adverse Credit Action associated with this application to the email address supplied in this Service Application.
  • In the event your account becomes delinquent and the account is placed with an attorney or a collection agency, collection fees, including but not limited to court costs and attorney fees together with interest, will be added to your account. Applicant acknowledges and consents to the Cooperative receiving and obtaining applicant’s credit report.
I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *