Application for Service

Please complete this application to apply for new service.  A credit check may be necessary to determine if a security deposit is required.  In addition to a security deposit, there may also be a connect and/or transfer fee required.

If you have any questions regarding setting up service, please feel free to contact our office at 800-454-5616 during normal business hours.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Applicant First Name:   *
Applicant Last Name:   *
SSN:--  *
Driver's License #:  *
License State:  
Date of Birth:    

Billing Address
Please enter the address where bills should be sent:

Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address
Please enter the street address where service is required:

Service Address:   *
Service Type (Construction Required or Existing Service):   *
If applicable, directions to new construction:  
E-mail:  *
Confirm E-mail:  *
Home Phone:--   *
Cell Phone:--  
Work Phone:--   
Co Applicant Name: 
Co Applicant SSN:-- 
Co Applicant Driver's License:  
Co Applicant License State:  
Co Applicant Birth Date:    
Co Applicant Employer:  

Online Access
We offer a varity of online services that our customers may use through our website.  As one of our services, we provide an online system for viewing and paying bills.  Please specify an internet password and password hint at this time.

Internet Password:  
Confirm Internet Password:  
Password Hint:

Existing Service
Have you ever had service with us before?

Account Number:

Fee & Deposit Information
When your account is created, you will receive an email with the total amount due on your new account if applicable.  Total amount due may be required before service is connected in your name.

Would you like to receive (at no charge) a printed copy of the cooperative’s monthly magazine?  *
Do you Own or Rent at this location?  
Please select a preferred Billing Method:  
I have read and understand the Member Handbook and applicable Bylaws of Cape Hatteras Electric Cooperative.  By submitting this application request, I also understand that a credit check may be submitted, if necessary, to determine if a security deposit is required.

I hereby apply for membership in Cape Hatteras Electric Cooperative, and to that end agree as follows. 

This institution is an equal opportunity provider, employer, and lender.

I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Member Name:     *