Are you applying for residential or commercial service?(Required) Residential Commercial Company Name(Required) Name(Required) First Last Social Security Number(Required) Mailing 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 Phone(Required)Service Address(Required) Same as 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 Single or Joint Membership(Required) Single Membership Joint Membership Spouse's Name(Required) First Last Are you a former member of the association?(Required) Yes No The following questions are voluntary information only. We are required by the Department of Agriculture to ask this for RUS Loan purposes:Ethnic Group Birthday (mm/dd/yyyy) Month Day Year Consent(Required) The applicant will pay a $5 membership fee, as set forth in the Articles of Incorporation of the Association. The applicant hereby grants at no cost to the Association a right-of-way easement to construct, operate, and maintain electric lines or system on the land where service is requested and in or upon all streets, roads, or highways abutting said land. The Association shall have at all reasonable times the right to access through its authorized employees and agents to the members' premises to install, inspect, or repair its lines or equipment, or to remove them upon termination of members' right to use. I agree, as a condition of membership, to be bound by and to comply with the Bylaws of the Association, and rules, regulations, and tariffs as may from time to time be adopted by the Association and are currently in effect. I understand that during the period of such membership, I will be entitled to all the privileges and subject to all the liabilities that such membership entails. I will not be personally liable for the debts of the Association. I agree to purchase from the Association all electric energy purchased for use on the premises served, pursuant to such membership. I further understand that, notwithstanding any other provisions for the termination of membership or service hereunder, my membership may be terminated at such time as I cease to purchase electrical utility service from the Association, and that if my account for such service is delinquent, or if I otherwise neglect or fail to pay any monies due the Association as agreed, or within the time specified by applicable rules and regulations, electric service hereunder may be discontinued at the option of the Association and without further consent of concurrence on my part. I hereby apply for membership in Kotzebue Electric Association, Inc. In support of this application, I submit the following information and agree to the conditions and terms hereinafter stated, it being mutually understood that references herein to the applicant are without regard to number or gender. I understand that by typing my full name and pressing the Submit button, this form submissionwill be stamped with today’s date and authorized by me as if I had signed my signature.Applicant Electronic Signature (Full Name)(Required) PhoneThis field is for validation purposes and should be left unchanged.
