Membership Application

To apply for membership or update your membership info, please complete the following:

Service Type

Are you an existing or new member?

First Name

Last Name

Company Name

Federal ID #

Date of Birth

Billing Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Primary Phone Number

Secondary Phone Number

Previous Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Contact Name

Contact Phone Number

Email Address

Do you have a joint applicant?

Yes

Joint Applicant

First Name of Joint Applicant

Last Name of Joint Applicant

Date of Birth for Joint Applicant

Email Address of Joint Applicant

Service Address Is Same As Billing Address

Service Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Desired Service Start Date

Automated Calling

By checking this box and providing a contact number, I authorize Parke County REMC (the “REMC”) and/or its agents, subsidiaries, or affiliated entities to deliver or cause to be delivered to the contact numbers provided informational messages, using an automatic telephone dialing system or an artificial or prerecorded voice, regardless of whether the number provided is a wireless or landline number. I understand that I am not required to provide such consent as a condition of receiving service from the REMC. By providing the number above for contact purposes, I am confirming that this number belongs to me and not to a family member or third party. I understand that I can revoke my consent or change the telephone number at which such messages are delivered to me by contacting the REMC at (800) 537-3913.

I agree to the terms of agreement.

Terms of Agreement

A Each Member shall make available either an easement or right-of-way to the Cooperative, as determined by the Cooperative, whereon to place the Cooperative’s physical facilities for the furnishing and metering of electric service and shall permit the Cooperative’s authorized Employees, Agents, and Independent Contractors to have access thereto for inspection, maintenance, tree trimming, replacement, relocation or repair, thereof at all reasonable times.

I request electric service from the Parke County Rural Electric Membership Corporation and make application for membership. I agree to purchase electric energy used at the location covered by this application, agree to pay any fees associated with this service including collection, attorney and legal fees and agree to be bound by the Articles of Incorporation, the By-Laws and amendments, and such rules and regulations as may be adopted from time to time by the Board of Directors. Policies are available upon request or at www.pcremc.com.

By signing below I am providing written authorization to Parke County Rural Electric Membership Corporation or its designee to review my personal consumer credit profile from one or more of the national credit bureaus. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purposes of updates, additional services and for reviewing or collecting the resulting account. If Parke County Rural Electric Membership Corporation decides to obtain a credit profile, I understand that it will provide, at my request, the name and address of the reporting agency and the nature and substance of information contained in such report.

Signature

Sign above

Date of Signature

Authorization

By checking this box, I am authorizing, to the best of my knowledge, the information stated above on this credit application is true and correct.

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CONTACT INFORMATION

5001 E US Highway 36, Rockville, IN 47872

(765) 569-3133 | (800) 537-3913

Contact Info