Consolidated Service Application | Citizens' Electric Company of Lewisburg, PA

Email

This field is for validation purposes and should be left unchanged.

Are you applying for service in our Union County, PA service area?*

Yes

No

Citizens' Electric Company serves customers in Lewisburg, PA and surrounding areas only.

This application is for service with Citizens' Electric Company of Lewisburg, PA.
Missouri residents should contact Citizens Electric Corporation.

Is this a residential service?

Yes (Residential)

No (Non-Residential)

"Residential" requires that the service will supply a private dwelling of at least 3 rooms including a separate bathroom, kitchen, living rooms.

PRIMARY APPLICANT

Business/Organization Name (if applicable)

Primary Contact*

First Middle Last Suffix

Applicant Name*

First Middle Last Suffix

EIN (if applicable)

*DO NOT provide your social security number here*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Service Address

Service Address is the same as the mailing address.

Service Address*

Street Address Address Line 2 City ZIP / Postal Code

Primary Phone*

Primary Phone Type

Alternate Phone

Alternate Phone Type

Primary Email*

Applicant is the:

Owner

Tenant

Landlord

Contractor

Other

Select all that apply

Name of Landlord, realtor, or owner:*

Please answer if you are a tenant.

Request is for:

New Service at a location not presently supplied by Citizens' Electric

Transfer of service at a location already supplied by Citizens' Electric

Other

Requested date of transfer:*

If a tenant, please discuss your transfer date with the landlord or owner.

New construction information will be requested at the end of this form.

Addtl Contact Choice

Specify an additional contact person for the account

ADDITIONAL CONTACT

Additional Contact*

First Middle Last Suffix

Additional Phone*

Phone

Additional Phone Type

Phone Type

Additional Email

Email

Is this contact authorized to discuss billing information?*

Yes

No

ADDITIONAL RESIDENTS

Will any other adults reside at the premise, or be named on the lease, deed or mortgage?*

Yes

No

An adult is an individual 18 or older, or an emancipated minor.

Additional Name(s)*

Additional Name - 1*

Additional Name - 2*

Additional Name - 3*

Additional Name - 4*

Additional Name - 5*

First Middle Last Suffix

Additional Name - 6*

Additional Name - 7*

Additional Name - 8*

Additional Name - 9*

Additional Name - 10*

Addtl Residents End

There are no additional residents who will reside at or be named with this address.

For any of the individuals listed on this application that are not already customers of Citizens' Electric, a company representative may contact you to request Social Security Numbers in order to process a credit check.

CONSENT & SIGNATURE

As part of the company's Electric Choice Program, customer information is provided to licensed generation suppliers operating in our service area. 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 choose No button below.

Release my information to licensed electric generation suppliers:*

Yes

No

ELECTRIC CHOICE

Primary Applicant

Digital Signature*

Type your full LEGAL name

Title

If applicable

Date*

Primary - POA / Authorized Rep

I am signing for the above individual as a POA or other authorized individual

Please explain

Citizens' may contact you to obtain proof of authorization.

Digital Signature of Authorized Representative*

Type your full LEGAL name

Title of Authorized Representative

If applicable

Date*

Electronic Signature Disclaimer

By signing above, I acknowledge and agree that my electronic signature, in the form of my typed, full, legal name, is legally equivalent to my handwritten signature and that I am bound by the terms and conditions of this agreement. I attest that am the individual whose name appears in the signature field or their authorized representative, as indicated, and that misrepresentation of my identity or use of another's name without authorization may constitute fraud.

Additional Applicant

Digital Signature

Type your full LEGAL name

Title

If applicable

Date

Additional - POA / Authorized Rep

I am signing for the above individual as a POA or other authorized individual

Please explain

Citizens' may contact you to obtain proof of authorization.

Digital Signature of Authorized Representative*

Type your full LEGAL name

Title of Authorized Representative

If applicable

Date*

Electronic Signature Disclaimer

By signing above, I acknowledge and agree that my electronic signature, in the form of my typed, full, legal name, is legally equivalent to my handwritten signature and that I am bound by the terms and conditions of this agreement. I attest that am the individual whose name appears in the signature field or their authorized representative, as indicated, and that misrepresentation of my identity or use of another's name without authorization may constitute fraud.

COMMENTS / OTHER INFO

Is there anything else you would like us to know?

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