Application for Membership Services

Please complete this application to apply for new service. All new applicants are required to pay a $10.00 membership fee before service is connected. Based on credit rating, a security deposit may also be required.

If you have any questions regarding setting up service, please email Kylie Jacobs kyliejacobs@mgemc.com. All fields with the asterisk (*) are required.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
First Name:   *
Last Name:   *
Middle Initial:  
Social Security Number:--  *
DL#:  *
License State:  
Birth Date:    
Employer:  

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

Service Address
Please enter the street address where service is required:
Service Address:  
Comments:  
E-mail:  *
Confirm E-mail:  *
Home Phone:--   *
Cell Phone:--  
Busniess Phone:--   
Spouse Name: 
Social Security Number:-- 
Co Applicant Driver's License:  
Co Applicant License State:  
Co Applicant Birth Date:    
Co Applicant Employer:  
DL#:  

Online Access
We offer a variety of online services that our customers may use through our website. As one of our services, we provide an online application for viewing and paying bills. Please specify an Internet Password and Password Hint at this time.
Internet Password:  *
Confirm Internet Password:  
Password Hint:

Existing Service
Have you ever had service with us before?    

Account Number:

Fee & Deposit Information
All new applicants are required to pay a $10.00 membership fee before service is connected. Based on credit rating, a security deposit between $0.00-$400.00 may also be required. 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:  

Which Source of Heat Will You Use?
(enter Gas , Wood/Other, Electric Heat or Solar/Renewable)		  *
If Electric Heat, Heat Pump or Geothermal?  
If applicable, would you like the Outdoor Light On or Off:
(enter N/A for not applicable)		  *
If applicable, Name of Landlord:  
Please select your status at service location:   *
Please select preferred Billing Method:   *
 
I agree to abide by the Membership Agreement, the policies, procedures, service rules regulations and bylaws of the cooperative. By checking this box, I also agree to receive correspondence regarding my account via text, email and voice. Furthermore, I understand these preferences can be managed via the online portal.
I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *