This agreement is between the person completing this form and Gulf Coast Electric Cooperative, Inc. concerning electric service located at or to be located at the address listed below.Name First Last PhoneAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Work Description New Overhead Service New Underground Service Existing Service Relocation of Service Retiring Service New Outdoor Light Service Upgrade Other Other Are you the owner of the listed property? I am the owner of the above listed property. I am not the owner of the above listed property. I understand that the property owner must also contact GCEC and execute an agreement. Property Owner's Name First Last Property Owner's TelephoneConsent(Required) As property owner, I understand that I am responsible for making sure that all items including, but not limited to: sprinkler systems, septic tanks/drain fields, underground pipes, concrete pads, pavers, grass, driveways, landscaping and/or fencing are marked and/or exposed. This agreement holds Gulf Coast Electric Cooperative, Inc. harmless for any injuries and/or damages that may occur as a result of this service request. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Members Electronic Signature (Full Name)(Required) Property Owner's Electronic Signature (Full Name)(Required) PhoneThis field is for validation purposes and should be left unchanged.
