APPLICATION FOR MEMBERSHIP FOR ELECTRIC SERVICE
Thank you for requesting service with Little Ocmulgee EMC. To request new service be connected, please complete the information below. A Member Service Representative will contact you within one business day to complete the application process or you will receive an automated email once your account has been officially created in our system.  If you have any questions regarding new service, please contact our office during normal business hours Monday-Friday, 8 am - 5 pm, 800-342-1290.

Note: All fields with the asterisk (*) are required. 

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
First Name:   *
Last Name:   *
Social Security #:--  *
Drivers License #:  *
License State:   *
Date of Birth:    
Employer Name:  
Cell Phone Provider:  *

Mailing Address:
Please provide the address where bills should be sent.
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address:
Please provide the physical 911 address.
Service Address:  
Comments:  
E-mail:  *
Confirm E-mail:  *
Home Phone Number:--   *
Cell Phone:--  
Employer Phone:--   
Spouse Information:
Name:		 
Social Security #:-- 
Driver's License #:  
License State:  
Date of Birth:    
Employer Name:  
Employer Phone:  

Online Access:
We offer a portal for online bill payment and account management. If you would like access to your account online, please create a password and password hint below. Please note passwords must be a combination of letters and numbers.
Internet Password:  
Confirm Internet Password:  
Password Hint:

Existing/Previous Service:
Have you ever had service with Little Ocmulgee EMC?    
Account Number:

Membership Fee:  
Account Establishment Fee:  

Would you like this to be a Prepay Account?
(yes/no):		  *
Personal Reference: Name:
(someone who knows you well and will be able to get in touch with you.)		  *
Street Address:  
City, State, Zip:  
Phone Number:  *
Do you own or rent?   *
Please select preferred Billing Method:   *
 
The undersigned (hereinafter called the "Applicant"), hereby applies for membership in, and agrees to purchase electric energy from The Little Ocmulgee Electric Membership Corporation (hereinafter called the "Cooperative"), upon the terms and conditions and/or prepay terms and conditions.  Acceptance of this application by the Cooperative shall constitute an agreement between the Applicant and the Cooperative. The contract for electric service shall continue in force from the date service is made available by the Cooperative to the Applicant, and therefore until cancelled by notice given by either party to the other.

APPLICANT REPRESENTS THAT THE INFORMATION GIVEN IN THIS APPLICATION IS COMPLETE AND ACCURATE AND AUTHORIZES US TO CHECK WITH CREDIT REPORTING AGENCIES, CREDIT REFERENCES AND OTHER SOURCES DISCLOSED HEREIN IN INVESTIGATING THE INFORMATION GIVEN.
I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *