Type of Service(Required)Please SelectStandard AccountPrepay AccountApplicant Name(Required) First Last Social Security Number(Required) Applicant's Place of Employment(Required) Email(Required) Phone(Required)Do you have a co-applicant?(Required) Yes No Co-Applicant's Name(Required) First Last Co-Applicant's Social Security Number(Required) Own or Rent(Required) Own Rent If renting - Landlord's Name? Previous Address(Required) 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 Mailing Address(Required) 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 New Service Address(Required) Same as previous 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 Please choose one of the following and explain so we can identify your service location:(Required)Please SelectPrevious Occupant911 AddressDirectionExplainDate Service Requested (mm/dd/yyyy)(Required) Month Day Year Include a copy of a photo ID for the person responsible for this account(Required)Max. file size: 170 MB.Member Consent(Required)The applicant, whose name appears below, is applying to the South Central Arkansas Electric Cooperative, Inc., of Arkadelphia, Arkansas for electric service to be supplied, at a nominal voltage of 120/240 volts, at the location herein described and, upon request, at any other location to which he or she may move within the area served by the Cooperative. The applicant agrees to pay for said service as bills are due in accordance with the bylaws and policies as provided by the board of directors of the Cooperative and further agrees to comply with rates, rules and regulations approved by the Arkansas Public Service Commission as they now exist or as may hereafter be adopted and in effect at the time of delivery. Appropriate fees must be paid before service will be connected. A cooperative representative will be contacting you for payment. The applicant further agrees to release and discharge said cooperative from any liability for damages suffered by reason of interruption, discontinuance or disconnection of service hereunder from any cause, or by reason of the maintenance, location or existence of any of the facilities, fixtures or systems located on or adjoining the property supplied and by which such services are furnished or delivered. 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.Member Electronic Signature (Full Name)(Required) Please select an identity question(Required)Please SelectCity of Birth?Mother's Middle Name?Father's Middle Name?Please answer the security question(Required) CAPTCHANameThis field is for validation purposes and should be left unchanged.
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