Start/Connect Service

 "*" indicates required fields

Date Service is Desired:  *  
 
Applicant Information:
First Name:		   *
Last Name:   *
Middle Initial:  
SSN:--  *

Billing/Mailing Information:
Full Name:   *
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Information:
Service Address:   *
City, State and Zip:   *
Please provide any additional information about the property (subdivision, lot number, pets, parking, locked gate, gate codes, etc.):
  *
E-mail:  *
Confirm E-mail:  *
Primary Phone Number:--   *
Spouse Information: (not required)
Name (First, Last and Middle Initial)		 
SSN:-- 


Preferred Billing Method:		  
 
• You may be assessed a security deposit based on information Walton EMC obtains from credit reporting agencies or other sources.     
• Submission of this form authorizes Walton EMC to obtain your credit information.
• To start your account, you will need to pay $5 for membership in the cooperative and a $30 account establishment fee.
• Please read Walton EMC's complete Terms and Conditions for Electric Service. 
• Please read Walton EMC's complete Service Rules.
• I certify that I am over 18 years of age and that I am authorized to request service for this address.
I signify that I have read, understand and accept Walton EMC's Terms and Conditions for Electric Service, Service Rules, Bylaws and the above statements.
  Applicant Name:     *