Name:_______________________________________________________ Date:___________________

Mailing Address:______________________________________________________________________

Service Address:_______________________________________________________________________

Home Telephone:_____________________________Work Telephone:__________________________

Electrician’s Name (if applicable):____________________________Telephone:__________________

Service Will Be For (circle one): Residence - Business - Irrigation - Gin - Lighting

Type of Structure (circle one): Mobile Home - 1 Story - 2 Story - Multi-Family #:___ - Commercial Building - Other

Size of Residence/Building in Square Feet: _____________

A/C Type and Size: Heat Pump(Tons):_______ Evaporative Cooler(HP):______ Air Conditioner(BTU):______

Type of Service Desired (circle one): Underground - Overhead

Size of Meter Base (circle one): 100 amp - 200 amp - 400 amp - Multi-Unit #:_____ - Other:_____

Service Voltage Desired (circle one): 120 - 120/240 - 240/480 - 120/208 - 277/480 - Other:__________

Please sketch a site plan of the proposed service  on the back and indicate the desired meter base location with an "X". Show the location of the home or structure, driveways, roads, property corners, drainfield, and nearest primary pole or padmount transformer. Include lot or parcel dimensions.

The above information is true and accurate to the best of my knowledge.

Signed:______________________ Date:________

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