Name(Required) First Last Phone(Required)Email(Required) 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 SCAEC Account Number(Required) Member Consent(Required)By including your full name above, you are authorizing South Central Arkansas Electric Cooperative, Inc (SCAEC) to enter your account into the levelized billing program. I understand that I can discontinue my participation in this program by notifying SCAEC in writing. SCAEC may terminate this agreement and remove my account from levelized billing any time payment is not received by the bill due date. I understand that I may be refused participation if my account is not current. Accounts removed from levelized billing will not be allowed to re-enter the program for a period of 1 year. 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) PhoneThis field is for validation purposes and should be left unchanged.