Apply for Service

Physical (911) Address of Property(Required)

Street Address Address Line 2 City State ZIP Code

Requested Date of Service (mm/dd/yyyy)(Required)

Member Information

Name(Required)

First Middle Initial Last

Social Security Number(Required)

Date of Birth (mm/dd/yyyy)(Required)

Home Phone(Required)

Cell Phone

Email(Required)

Current Employer(Required)

Employer Address(Required)

Street Address Address Line 2 City State ZIP Code

Have We Served You Before?(Required)

Yes

No

When?(Required)

Are you renting?(Required)

Yes

No

Name of Landlord(Required)

First Last

Phone Number of Landlord(Required)

Co-Applicant Information

Do You Have a Co-Applicant?(Required)

Yes

No

Joint/Co-Applicant Name(Required)

First Last

Joint Applicant's Social Security Number(Required)

Joint Applicant's Date of Birth (mm/dd/yyyy)(Required)

Joint Applicant's Home Phone(Required)

Joint Applicant's Cell Phone

Joint Applicant's Driver's License Number and State(Required)

Joint Applicant's Employer(Required)

Joint Applicant's Employer's Phone Number(Required)

Service Information

If Existing Customer, List Meter Number

Address(Required)

City State ZIP Code

Phone at Location

Subdivision or Condo Name and Lot Number

County(Required)

Current Billing Address(Required)

Same as Physical (911) Address of Property

Street Address Address Line 2 City State ZIP Code

Agreement & Signature

Member Consent(Required)

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.

The above (herinafter called the Applicant(s) hereby applies for membership in and agrees to purchase electric service from RushShelby Energy (herinafter called the Cooperative) upon the following terms and conditions.

The Member(s) will, when energy becomes available purchase from the Cooperative the electric energy used or agreed upon if other sources are used on the premises at rates to be determined from time to time in accordance with the By-laws of the Cooperative and understands that electric service charges are due when rendered. The member(s) signing this application agrees that he/she shall be jointly liable for all debts of the Applicant(s) incurred pursuant to this membership.

In the event that it shall become necessary to resort to debt collection policies for the collection of any sum of money due the Cooperative under this membership, then the Member(s) agrees to pay all reasonable expenses of collection including the reasonable attorney’s fee in addition to the amount due the Cooperative.

The Member(s) will cause his/her service entrance to be wired in accordance with the wiring specifications approved by the Cooperative.

The Member(s) will comply with and be bound by the provision of the Certificate of Incorporation and the By-Laws of the Cooperative and such rules and regulations as may from time to time be adopted by the Cooperative.

The Member(s) agrees that pole or poles and apparatuses thereto and/or any underground construction deemed necessary by the Cooperative may be placed on the premises so as to best render service to the Member(s) and that ownership of such construction shall be vested to the Cooperative. The member(s) also agrees that employees of the Cooperative shall have the right to ingress and egress on said premises up to the location of the meter installation as long as any property of the Cooperative remains on said premise.

The Member(s) understands that an on-line credit check will be performed to determine whether a deposit needs to be applied on said account. If a deposit is charged the Member(s) agrees that a deposit of $150 or $300 will be billed to the first month’s bill.

The Member(s) understands that a New Account Fee of $30 will be applied to the first month’s bill.

The facts set forth above in my application for service are true and complete to the best of my knowledge.

Member Electronic Signature (Full Name)(Required)

Application for Service

Member Information

Co-Applicant Information

Service Information

Agreement & Signature