Connect Or Disconnect Form - Electric Service Request

Download a blank fillable Connect Or Disconnect Form - Electric Service Request in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Connect Or Disconnect Form - Electric Service Request with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

STEAMBOAT

CRAIG

Physical & Mailing: 2211 Elk River

YAMPA VALLEY ELECTRIC ASSOCIATION, INC.

Physical: 435 Mack Lane, Suite 203

Road Steamboat Spgs, CO 80487

(Yampa Valley Bank)

ELECTRIC SERVICE REQUEST

Mailing: 3715 E. US 40 Craig, CO 81625

Fax: 970-871-2271

Phone: 970-879-1160

PLEASE PRINT

Phone: 970-879-1160

Email:

(Check which service you are seeking:)

NEW CONSTRUCTION

DISCONNECT

CONNECT

TODAY’S DATE: ________________________ SERVICE EFFECTIVE DATE : ______________________

APPLICANT: _________________________________________________________

________________

Last

First

Middle Initial

Social Security or Tax ID #

SPOUSAL APPLICANT: ________________________________________________

_________________

Last

First

Middle Initial

Social Security #

IN CARE OF: _____________________________________________________________________________

MAILING ADDRESS: ______________________________________________________________________

CITY: ______________________________________STATE____________________ZIP_________________

PHYSICAL ADDRESS OF SERVICE: ______________________________________________ Lot #_____

CHECK APPROPRIATE TYPE OF SERVICE: COMMERCIAL

RESIDENTIAL

CONDO/TOWNHOME/APT. NAME: ______________________________________ UNIT #: ___________

CITY:_______________________________________STATE____________________ZIP________________

CHECK THE APPROPRIATE BOX: I AM THE OWNER

I AM A RENTER

IS THIS A 30 DAY OR LESS RENTAL UNIT:

YES

PREVIOUS PERSON AT THIS LOCATION (

_________________________________________

IF KNOWN): _

The Applicant agrees to be responsible for the electric charges at the location designated above until such time that the Applicant requests and receives

discontinuance of service. It is agreed that all bills will be paid by the appropriate due date and failure to do so may result in discontinuance of service.

This Application for Electric Service shall constitute a service contract between the Applicant and the Association, a grant of security interests in

applicant's future capital credits, and the Applicant agrees to be bound by the Bylaws, Rules and Regulations of the Association. The applicant agrees

that any information contained in this request may be used to collect on a delinquent account. The Applicant also agrees to pay late fees (penalty

interest) of 1.5% per month on all delinquent charges until paid in full, and agrees to promptly reimburse the Association for all collection costs and

attorney's fees incurred by the Association to collect delinquent amounts owed on Applicant's account after default. Unless the "NO" box is checked

immediately below, Applicant agrees to participate in YVEA's Round-Up Program so that each monthly bill will be rounded up to the next

dollar and the accumulated round-up funds will be given to YVEA's Caring Consumers Foundation dba/Operation RoundUp for distribution

for charitable purposes.

No, I elect not to participate in YVEA's Round-Up Program.

Yes, I want to participate in YVEA's Automated Bank Draft Payment program (additional form required).

Employer: _________________________________ Employer’s Phone #: __________________________

Home Phone # ____________________________ Cell Phone #: _______________________________

Birthdate: ______________________ Email Address: ___________________________________________

Applicant’s Driver License # _____________________________STATE ISSUED: ___________________

The Applicant certifies that the information provided is true and accurate:

Signature of Applicant:_________________________________________________________

Remarks:

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

FOR YVEA OFFICE USE ONLY:

Previous YVEA Account #: _______________________________

Ser. Map Loc #: __________________

Meter #: ________________ YVEA Member #: _______________

Security Deposit Amount Required: $___________________ Connect Fee: $__________________________