Application for Electric Service
And Membership

Please complete this application to apply for new service with Escambia River Electric Cooperative. If location has never had power before, please call our office at 1-800-235-3848 to set up an appointment for site survey. All new applicants are required to pay a membership fee and a connect fee. If applicable, a credit check may also be necessary to detemine if a security deposit is required. If you are renting at this location, a rental form completed by Landlord/Rental Agency is required. Please fax a copy of this document to 1-850-675-8415.      

If you have any questions regarding setting up service, please feel free to contact our office.

Please Note: All fields with the asterisk (*) are required.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Applicant's Legal First Name:   *
Applicant's Legal Last Name:   *
Social Security #:-  -   *
Driver's License #:  *
License State:  
Birth Date:    
Exp Date:  
Date of Birth:  

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

Service Address
Physical address of service location:
Service Address:  
Service Type (Construction Required or Existing Service):   *
Driving Directions (If location has never had power before):  
E-mail:  *
Confirm E-mail:  *
Home Phone:-  -    *
Cell Phone:-  -   
Busniess Phone:-  -     
Spouse Legal Name (if Joint Aplication): 
Social Security #:-  -   
Co Applicant Driver's License:  
Co Applicant License State:  
Co Applicant Birth Date:    
Co Applicant Employer:  
Driver's License #:  
Exp Date:  
Date of Birth:  
Business Phone #:  
Cell Phone #:  

Online Access
We offer a variety of online services that our members may use through our website. As one of our services, we provide an online system for viewing and paying bills. Please create an Internet Password and Password Hint to access the online system.
Internet Password:  
Confirm Internet Password:  
Password Hint:

Existing Service
Have you ever had service with Escambia River Electric Cooperative before?
Account Number:
Fee & Deposit Information
A $5.00 membership fee and a $25.00 connect fee are required for connection of new service. In addition, a deposit may also be required. The deposit amount is determined based on a credit check. When your account is created, you will receive an email with the total amount due on your new account, including the deposit amount, if applicable.

Membership Fee:  
Connect Fee  

Name of Landlord/Rental Agency:  
Landlord Phone #:  
Please confirm if you Own or Rent this location?   *
Please select preferred Billing Method:   *
As Escambia River Electric Cooperative, Inc. requires a credit check before waiving security deposits, the applicant(s) consents and authorizes Escambia Rver Electric Cooperative, Inc. to obtain a consumer credit report on the applicant(s) for such purpose, by checking the box I (we) agree. I Furthermore Certify That I Am At Least 18 Years Of Age And All The Above Information Is Correct To The Best Of My Knowledge.