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:   *
 
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. 

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.

You agree, in order for us to service your account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide us. Methods of contact may include using pre-recorded or artificial voice messages and/or the use of an automatic dialing device, as applicable. I/We have read this disclosure and agree that Amicalola Electric Membership Corporation may contact me/us as described above.
I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *