Central Florida Electric Cooperative, Inc.

Service Agreement Form

By submitting this application electronically, the applicant hereby applies for electric service to be provided by the Central Florida Electric Cooperative, Inc (CFEC) and authorizes CFEC to perform a credit check to determine credit-worthiness and establish positive identification. CFEC will require a copy of your rental/lease agreement, government issued ID, and a notarized membership application. Furthermore, the applicant agrees to pay the applicable connect fees, security deposits based on credit analysis and be bound by all provisions in CFEC's Bylaws and Service Rules and Regulations, along with all applicable laws, rules, regulations, statutes, and ordinances as they may now exist and as they may be modified from time to time.

Any information obtained in connection with the Membership Application and Service Agreement will be used by CFEC for credit purposes only and no information received will be distributed to any third party except in an effort to collect upon the account.

Please complete and summit the following information. A customer service representative will contact you within 24 hours to complete your application.

* Indicates required field

Meter Number:(Located inside the meter glass on a silver tab)

Member Information

* First Name

MI:

* Last Name

* SSN:

SSN2

SSN3

* Date Of Birth:

DAY

YEAR

* Drivers License State

* Drivers License No:

* Current Mailing Address:

* City:

* State

* Zip:

* Home Phone:

PHONE2

PHONE3

* Email Address:

* Cell Phone:

CELLPHONE2

CELLPHONE3

* Service Address:

* City:

State

* Zip:

Spouse Contact:

First Name:

MI:

Last Name:

SSN:

SSN2a

SSN3a

Date Of Birth

dob2

dob3

* I am the primary tenant/resident at the above listed address:

Yes

Names of other adults living in the household:

* - I also attest to the fact that the previous tenant/resident no longer resides at this address and that I have reviewed all the information above and verified that it is correct.

Service Connection Date

* What date would you like the service connected?

(mm/dd/yyyy format)

SUBMIT CANCEL