Application to Coast Electric Power Association
All fields indicated with an * are required.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
First Name:   *
Last Name:   *
Middle Initial:  
SSN:--  *
License State:  
Birth Date:    
Applicant’s Employer:  
Employer Address:  
City, State & Zip:  
Employer Phone:  
Do you own your home? (Yes/No)  
If you rent, specify Rental Agent:
Please note, if renting, a lease agreement will be required.		  

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

Please enter the address where service is required:
    Service Address:   *
    Service Type (Construction Required or Existing Service):   *
    If applicable, directions to new construction:  
    E-mail:  *
    Confirm E-mail:  *
    Home Phone:--   *
    Cell Phone:--  
    Co Applicant’s Name: 
    Co Applicant’s SSN:-- 
    Co Applicant Driver's License:  
    Co Applicant License State:  
    Co Applicant Birth Date:    
    Co Applicant Employer:  
    Employer Address:  
    Employer Phone:  
    Relative’s Name:  
    Relative’s Address:  
    Relative’s Phone:  

    As one of our services, we provide an online application for viewing and paying bills. If you'd like to use this service, you can specify an Internet Password and Password Hint at this time. Please note that the Internet Password must be at least 4 characters in length.
    Internet Password:  
    Confirm Internet Password:  
    Password Hint:

    Do you currently use, or have you used Coast Electric before?    
    Account Number:
    Note: A refundable deposit will be required on each account.  You will receive an email from Coast Electric Power Association to verify the address entered. You MUST reply to the email in order to activate this request.

    Membership Fee:  
    Service Charge:  

    Previous Address:  
    City, State:  
    Zip Code:  
    Credit Reference of current Coast EPA member: Member Name:  
    Member Account Number:  
    Would you like to sign up for alerts to your cell phone?  *
     
    I (hereinafter called the “Applicant”) have read and agree to the APPLICATION FOR MEMBERSHIP AND SERVICE CONTRACT and hereby apply for membership and agree to purchase electric energy from Coast Electric Power Association (hereinafter called the “Association”).