Apply for Commercial Service Business Name* Legal Name of Business Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Service Effective Date* Date Format: MM slash DD slash YYYY Applicant is:* Owner Builder Electrician Tenant Other Request is for:*Service at a location already served by Citizens’ ElectricNew service at a location not presently served by Citizens' ElectricContact Name* First Last Address where service is requested*If you will be renting, name of landlord, realtor or person to whom you pay rent:As part of the Electric Choice Program, customer information will be provided to licensed generation suppliers. This information includes your name, billing address, service address, account number and electric usage information. This allows suppliers to provide you with information about their services and makes it easier for you to take part in Electric Choice. Suppliers are required to keep your account information confidential. PUC regulations require that we release your account and electric usage information to electric generation suppliers. If you do not want your information released please check the box below. Do not release any information to licensed electric generation suppliers. • To help prevent identity fraud, we will require the Social Security Number and EIN of all applicants. A Customer Service Representative will contact you at the number you provided to request this information. You can also call us at 570-524-2231 to provide this info. You may opt out of providing your SSN. Opting out will limit our ability to verify your credit history, so a deposit may be required. • You will be advised if a cash deposit is required as a condition of receiving permanent service. • If application is for service at a location not previously served by Citizens’ Electric, please continue on to complete the NEW CONSTRUCTION INFORMATION below. • If you are applying for service at an existing location served by Citizens' Electric, please scroll down to the signatures area. • Your account will be charged 6% Sales & Use tax unless a PA Exemption Certificate is received. If all or a portion of your company is tax exempt, please fill out a PA exemption form (available at https://smartpay.gsa.gov/sites/default/files/wysiwyg/PA%20REV-1220AS.pdf) and return it to Citizens' Electric. Your account will be charged 6% until this form is received. The completed form can be emailed to firstname.lastname@example.org, faxed to 570-524-5887, or sent via US Mail to 1775 Industrial Blvd, Lewisburg PA, 17837.New construction information Please provide as much information as possible. What type of service are you requesting? Permanent Service Temporary Service Overhead Underground Single-Phase Thee-Phase (Check all that apply)Service Size (Amps)Service Voltage Required120/240 Single Phase120/240 Three-Phase Delta (by Company approval only)120/208 Y277/480 YConstruction StatusIn designLand clearedFoundation inWalls upUnder roofCompleteElectrician's Name First Last Electrician's Address Street Address City Electrician's PhoneBuilder's Name First Last Builder's Address Street Address City Builder's PhoneNearest pole or pad #Approximate distance to pole or pad(feet)Total Square Feet Under RoofPlease provide the single and/or three phase loads in kW for the following:CookingkWSpace HeatingkWRefrigerationkWElevatorskWWater HeatingkWLightingkWMotorskWPoolkWAir ConditioningkWProcess HeatingkWComputerskWOther (list)kWEstimated peak demand in kW for SummerkWEstimated peak load in kW for WinterkWPlease describe any unusual loadsHorsepower and voltage of largest motorEstimated power factorThank you for your information.Signature(s) Primary Digital Signature - Please type your full name*TitleDate Date Format: MM slash DD slash YYYY Secondary Digital Signature (if applicable) - Please type your full nameTitleDate Date Format: MM slash DD slash YYYY CommentConsent* I/We agree to the application terms.The applicant agrees to abide by the established rules and regulations of Citizens’ Electric Company of Lewisburg, PA, now in force, or which may hereafter be enacted or adopted for the governance and regulation of said Company, and to pay for service at the adopted rates as filed with the Pennsylvania Public Utility Commission or any subsequent rates which may be filed and accepted by the Pennsylvania Public Utility Commission. Rules, regulations and rate schedules are on file and may be inspected at the Company office. Failure to notify the Company of your intent to terminate service and/or pay your account in full upon such termination will result in the Company using those legal remedies available to secure full payment and all associated costs.NameThis field is for validation purposes and should be left unchanged.