Request Connect Date:
  ** dates selected on holidays will be moved to the next business day
Permit Number:
Yes, This is a Joint Account
Home Owner
(A completed Owner/Rental Form is required before service can be activated.)
Landlord or Rental Agency: Phone:
 
Service Description
Service Description: (House, Well, etc.)
Service Address: County:
City: Is the location in the city limits:
Driving Directions:
 
Applicant's Information
W-9   Legal Name: Soc. Sec. Nbr:
       
Addr Line 1: Previous Addr Line 1:
Addr Line 2: Previous Addr Line 2:
City: City:
State: State:
Zip: Zip:
           
E-mail: Fax: Date of Birth:
Primary Phone: Employer Phone: Alternate Phone:
DL or ID Nbr: State: Exp Date:
 
Joint Applicant's Information
Legal Name: Soc Sec Nbr:
Date of Birth: Employer Phone: Alternate Phone:
DL or ID Nbr: State: Exp Date:
 
Residential Use
 
The State of Florida requires that sales tax be charged on the sale of electricity unless it is sold for exempt purposes.
The main exempt Purpose is:
Residential household use; if any part of the power is for non-exempt purposes, then tax must be paid.
By the selection below, I declare that the use of electricity at this property is exclusively for residential use. I understand if the usage changes, it is my responsibility to notify CHELCO.
 
Yes, I am Tax Exempt
No, I am not Tax Exempt
 

Required for New Services

I understand that if additional facilities must be constructed to serve a requested location, the cooperative will provide me with a Work Proposal and I must pay the required Cost In Aid to Construction (CIAC). Proposals are valid for 90 days, and total CIAC must be paid prior to installation of CHELCO facilities.  Any deviation from facilities agreed upon, including but not limited to, changing the closest point of attachment (POA) or changing the facilities from overhead to underground will result in additional CIAC. All facilities installed and maintained by CHELCO, are and will remain the sole property of CHELCO.

Initials: Date:
 
Applicant Signature
I CERTIFY, BY ENTERING MY NAME AND DATE BELOW THAT I AM AT LEAST 18 YEARS OF AGE AND ALL OF THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.
Initials: Date:
 
Joint Applicants Signature
I CERTIFY, BY ENTERING MY NAME AND DATE BELOW THAT I AM AT LEAST 18 YEARS OF AGE AND ALL OF THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.
Initials: Date:
 

Identity Verification Authorization

In order to comply with the Federal Trade Commission’s Identity Theft Program, Choctawhatchee Electric Cooperative, Inc. requires a credit check as part of identity validation.  The undersigned consents to and authorizes CHELCO to obtain a consumer credit report for such purpose.  Please acknowledge your acceptance of the stated condition by entering your initials and date below.
Initials: Date:
Joint Initials: Date:
 
Deposit Waiver Authorization

Choctawhatchee Electric Cooperative, Inc. requires a credit check before waiving the security deposit. In order to comply with Fair and Accurate Credit Transaction Act of 2003 the undersigned consents to and authorizes CHELCO to obtain a consumer credit report for such purpose.  Please acknowledge your acceptance of the stated condition by entering your initials and date below.
Initials: Date:
Joint Initials: Date:
 
 
Membership

GENERAL CONDITIONS
And
TERMS of AGREEMENT
 
  1. The applicant shall pay the Cooperative the sum of $5.00, which will constitute the applicant’s membership fee.  The applicant, by paying the membership fee and becoming a member, assumes no personal liability or responsibility for any debts or liabilities of the Cooperative and it is expressly understood that under the law his private property cannot be attached for any such debts or liabilities.  The acceptance of this application by the Cooperative shall constitute an agreement between the applicant and the Cooperative.  The applicant hereby agrees to abide by the rules, regulations and Bylaws of the Cooperative.

  2. The applicant attests by the submission of this request for service financial responsibility, ability and willingness to pay our invoices in accordance with the following terms and conditions:  Terms of payment are net 21 from the date of the invoice. Late fees in the amount of 10% up to $25.00 and 2% on balances over $25.00 will be assessed on the 22nd day after the invoice date when the account will be considered in default.  Service is subject for disconnection after the 13th day the account is in default (34 days after the invoice date). 

  3. The applicant will be responsible for collection fees, attorney’s fees, court costs and interest, if default litigation occurs. 

  4. The applicant consents that the Cooperative by its agents, servants, employees or representatives shall at all reasonable times have the right to ingress or egress, to and from the premises described below for the purpose of reading, installation, removal or repair of any meter on said premises and for such other purposes as shall be necessary or incident to the maintenance of the service herein applied for.

  5. The applicant will cause his/her premises to be wired in accordance with wiring specifications approved by the Cooperative and the applicable government agencies.

  6. The applicant agrees that properly chargeable installation, repairs, and maintenance and energy shall be collectively and separately considered part of the energy and service charges to be paid monthly as the same shall accrue and that the failure or refusal to pay them or any part of them when due shall subject the applicant to the rules and regulations of the Cooperative relating to discontinuance of service.

  7. The applicant will keep the Cooperative informed of their current mailing address.  The applicant further understands that all undeliverable checks (capital credit, deposit, etc.) returned to the Cooperative will be assessed monthly service charges until claimed.

  8. As a member of the Cooperative, applicant shall be eligible to vote for Board Trustees by mail ballot.  Each member may vote once and only one person may vote for each account as described in the Bylaws of the Cooperative.

  9. The Cooperative will make every effort to maintain continuous service: however, the Cooperative will not guarantee such service to be 100 percent, and reserves the right to make emergency repairs on its lines and is not responsible for loss of property due to outages or power surges which are results of floods, strikes, riots, emergency maintenance, acts of God, outages by its power supplier, nor any other outage or power surges beyond its control.

  10. Payment for electricity shall include an annual subscription to the CHELCO News.

THIS AGREEMENT SHALL BE ENFORCED IN ACCORDANCE WITH THE LAWS OF THE STATE OF FLORIDA.  THE ABOVE INFORMATION IS FOR THE PURPOSE OF OBTAINING CREDIT AND ANY INFORMATION PROVICED WILL BE USED TO COLLECT UNPAID DEBT.

I DO APPLY TO CHOCTAWHATCHEE ELECTRIC COOPERATIVE, INC. FOR MEMBERSHIP IN ACCORDANCE WITH THE TERMS AND CONDITIONS CONTAINED IN “GENERAL CONDITIONS” TO ALL OF WHICH I AGREE.
 
Initials: Date:
 
I understand that by initialing in the form above represents my digital signature.
 
 
 
Since you are renting a complete Owner/Renter form is required before service can be activated.
Click here to print a Owner/Renter Form.