Application for Residential Service - Petit Jean Electric Cooperative

Applicant Full Name *

Email Address *

Applicant Social Security Number

Please provide your full Social Security number in the field above. If this field is left blank, a Customer Service Representative will collect it during the return phone call.

Applicant Date of Birth *

Applicant Identification (Drivers License, State ID Card, Military ID, Passport, or I-551). File types accepted: JPEG, JPG, PDF, PNG. *

(jpg, jpeg, png, pdf, dwg)

Copy of Lease/Rental Agreement or Proof of Home Ownership *

(jpg, jpeg, png, pdf, dwg)

Applicant Primary Phone Number *

Applicant Additional Phone Number

Applicant Place of Employment

Applicant Work Phone Number

Is this a joint application? *

Yes No

Note: This section must be entirely completed in order to add a joint account holder.

Co-Applicant Full Name *

Co-Applicant Social Security Number

Please provide your full Social Security number in the field above. If this field is left blank, a Customer Service Representative will collect it during the return phone call.

Co-Applicant Date of Birth *

Co-Applicant Identification (Drivers License, State ID Card, Military ID, Passport, or I-551) *

(jpg, jpeg, png, pdf, dwg)

Co-Applicant Primary Phone Number *

Co-Applicant Additional Phone Number

Co-Applicant Place of Employment

Co-Applicant Work Phone Number

Co-Applicant Email Address

Do you currently have active service with Petit Jean? *

Yes No

Enter your account number

A membership fee of $20 (refundable) must be paid.

Is there an existing meter at this location? *

Yes No

I have reviewed the Residential New Construction Checklist *

Yes, I have reviewed the checklist.

Please Specify

Lot

Block

Phase

Subdivision

What is this service for? (Ex: house, barn, boat dock, etc.) *

Site Information:

Is the following installed at this site? If None, additional costs will apply for an unqualified load. *

Yes, I understand additional costs will apply if there is not a Sanitation System, Pressurized Water System, or a Permanent Foundation at this site.

Please Specify

What type of Sanitation System is at this site? (Sanitary Sewer, Septic or None) *

What type of Pressurized Water Service is at this site? (City, Well, or None) *

Is there a Permanent Foundation on this site? *

Yes No

What is the meter number? *

I have reviewed the Residential Service Checklist *

Yes, I have reviewed the Residential Service checklist.

Please Specify

Would you like to have a new Security Light installed at this location? Installation is free of charge. The standard residential Security Light charge for a residential 175 W LED is $8.31 per month.

Yes No

Meter Base Package Release

I hereby acknowledge receipt of and accept full ownership of the following described material(s) from Petit Jean Electric Cooperative upon the following terms and conditions:

Please select a meter base package *

Please Specify

Upon installation by the Cooperative, I assume all responsibility and control of all material(s) obtained hereunder. Any costs for repair, replacement, or removal of the material(s) shall be at my expense. I understand that a licensed electrician should be the only party who repairs, replaces, or removes the materials. If the materials are installed in an area where an official inspection is required by any government agency, or any county, city, or other controlling entity, I agree that I am completely responsible for having the materials and/or installation inspected by an appropriate expert. The Cooperative will work with all local inspection offices to ensure a proper installation.

I agree to indemnify and save and hold the Cooperative harmless from any liability from any cause whatsoever that might be claimed by me, any subsequent owner, or any person or entity, claiming damages by virtue of or in any manner arising out of a defect in the material(s), the use or condition of the material(s), or any other function or circumstances relating to the material(s). In the event any legal action is brought against the Cooperative by any party for any reason regarding a defect in the material(s), the undersigned agrees to reimburse the Cooperative for any and all costs, charges, expenses, judgments, or otherwise, together with it's attorney's fees and costs, to investigate and/or defend such claims. *

Yes, I agree.

Please Specify

Signature(s) *

Are there multiple meters at this location? *

Yes No

Please list the meter number(s) you would like to establish service for. *

Requested Service Start Date (All new connects will be made in accordance with Arkansas Public Service Commission rules. If the date is sooner than the rules allow, please note your actual connect date will be made as soon as possible.) *

Service Location Physical Address/911 Address *

City *

State *

Zip Code *

Billing Address *

City *

State *

Zip Code *

Previous Billing Address

City

State

Zip Code

Service Deposit of $200.00 (refundable with interest) must be paid. In lieu of cash deposit, you may provide a good letter of credit rating for the previous 12 months from a former utility. Would you like to provide a letter of credit? *

No, I will not provide a letter of credit. Yes, I have a letter of credit available to upload. Yes, the letter of credit has been faxed or emailed to Petit Jean.

Please Specify

Upload Letter of Credit below. *

(jpg, jpeg, png, pdf, dwg)

Please enter specific details below.

I am the:

Homeowner

Yes No

Tenant

Yes No

Landlord's Name *

Landlord

Yes No

Tenant's Name *

Mark below if your account should be marked as:

Age 65 or older

Yes No

Handicapped (Doctor's certification required)

Yes No

Types of certifications accepted: certification from a physician, licensed psychologist, by the United States, Veteran’s Administration, the Social Security Administration, the Arkansas Department of Human Services, the Arkansas State Hospital, or a licensed mental health center. *

(jpg, jpeg, png, pdf, dwg)

If there is a security light at this location, would you like to keep it? *

Yes No

I choose to keep the security light(s) that are currently connected at my account location and agree to pay the associated monthly service fee(s). For more information, click here.

I choose to disconnect the security light(s) that are currently connected at my account location and do not want to pay the associated monthly service fee(s). I also understand that if I were to choose to reconnect the security light(s) at a later date, a security light reconnect fee of $50 will be charged per light.

Would you like to enroll in Electronic Billing (eBilling)?

Yes No

eBilling Email Address

Would you like to enroll in eDraft? *

Yes No

I authorize Petit Jean to electronically debit my account monthly for the amount stated on my bill(s) and if necessary, electronically credit my account to correct erroneous debits. I understand this authorization remains in full force and effect until I notify Petit Jean in writing, at least five days before the due date *

Yes, I agree.

Please Specify

Type of Bank Account *

Please Specify

Bank Routing Number (maximum of 9 numbers) *

Bank Account Number (maximum of 15 numbers) *

Name(s) on Bank Account *

Name of Bank *

City/State of Bank *

Upload copy of voided check. This will only be used to verify bank account information entered above. *

(jpg, jpeg, png, pdf, dwg)

The Applicant, whose signature appears below, applies to the PETIT JEAN ELECTRIC COOPERATIVE of Clinton, Arkansas, (hereinafter called the "Cooperative") for membership and/or electric service to be supplied at the location herein described and, upon request, at any other location within the area served by this Cooperative. This agreement shall supersede and replace any previous agreement and shall apply to each location the Cooperative furnishes electric service to the applicant.

I hereby apply to Petit Jean Electric Cooperative for Membership and/or electric service with the terms and conditions appearing here.

Signature *

Co-Applicant Signature