Application for New Service

(Please note that all applications for service are subject to credit check)

For locations that have had prior electric service, we offer same day service at no additional charge for applications received before 3 p.m. For a $25 fee, applications received between 3 p.m. and 5 p.m. can also be connected the same day.

Otherwise, applications received after 3 p.m. will be connected the next business day.

Information on this application will be used for the purpose of a credit check. Depending upon the results of your credit check, you may be required to pay a deposit in full prior to electric service being connected.

In lieu of paying a deposit we offer an attractive Advance Pay account. With Advance Pay there are no monthly bills, deposits or late fees. Only $83.00 is needed to start. Included is the $5.00 Membership Fee (refundable) and a $28.00 Activation Fee (non-refundable). The remaining $50 is the initial prepaid advance credit applied to your account. If you are interested in this option, please indicate "yes" in the Prepay field area below.

NOTE: All fields with a RED (*) are required. After clicking submit, you should get a confirmation page and a confirmation email. If you do not, then the application has not been submitted.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
First Name:   *
Last Name:   *
Middle Initial:  
Social Security #:-  -   *
Driver’s License #:  *
License State:  
Birth Date:    
Employer’s Address:  
Next of Kin:  
Next of Kin Address:  
Next of Kin Phone #:  

Billing Address
Please enter the address where bills should be sent:

Care of Address:  
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address
Please enter the address where service is required:

Service Address:  
Service Type (Construction Required or Existing Service):   *
Meter #:  
If applicable, directions to new construction:  
E-mail:  *
Confirm E-mail:  *
Home Phone #:-  -    *
Cell Phone:-  -   
Business Phone #:-  -     
Spouse’s Name: 
Spouse’s SSN:-  -   
Spouse Driver's License:  
Spouse License State:  
Spouse Birth Date:    
Spouse Employer:  

Online Services
As one of our services, we provide an online application for viewing and paying bills. Please specify an Internet Password and Password Hint at this time.

Internet Password:  *
Confirm Internet Password:  
Password Hint:

Existing Service
Have you ever had service with Coastal Electric Cooperative previously?

Account Number:

Membership Fee:  
Service Charge:  

I hereby reject the voluntary Operation Round Up® contribution (initial only if rejecting contribution)  
Please select your preferred Billing Method:   *
I, the above named applicant, (hereinafter called the Member-Owner), hereby apply for electric service and agree to purchase electric energy from Coastal Electric Cooperative (hereinafter called the Corporation), under the following terms and conditions:

1. The Member-Owner will pay service charges and/or membership fees as indicated above, along with any deposits that may be required.

2. The Member-Owner will comply and be bound by the provisions of the Bylaws of the Corporation and the Service Rules and Regulations.

I understand that checking this box and typing my name in the field provided below is my electronic signature. Advance Pay Applicants acknowledge that you have read and that you accept the Advance Pay Terms and Conditions. 
  Applicant Name:     *