Application for Membership and Electric Service

Please complete the below form to apply for new service.   Note, service is connected Monday-Friday between the hours of 8am and 3pm and cannot be connected on weekends or holidays. A $25.00 membership fee is required from all applicants.  A deposit may also be required.  Once your account is created in our system, you will receive an email which includes the total amount due.

For Residential Accounts: Service will not be connected until a copy of your driver's license is emailed to and the balance due is paid.

For Commerical Accounts: Service will not be connected until a copy of your Federal Tax ID number from a Merchant ID or similar form is emailed to and the balance due is paid.

If you have any questions regarding new service, please feel free to contact our office during normal business hours 574.267.6331.

Note: All fields with the asterisk (*) are required.

Today's Date:
Fecha de hoy:

Fecha Servicio se Desea:
Date Service is Desired:  *  
Type of Request:   *
First Name:
Last Name:   *
Middle Initial:  
SSN:--  *
Date of Birth:  *  

Mailing Address:
Direccion Para ElCorreo:
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Physical Address: (Of Service)
Direccion Fisica:(Para El Servicio)
Service Address:   *
E-mail:  *
Confirm E-mail:  *
Home Phone:--   *
Cell Phone:--  
Work Phone:--   
Spouse or Other Adult Living at Residence:
Full Name:
Date of Birth:    
Cell Phone:  
Work Phone:  

Internet Password:
As one of our services, we provide an online portal for account management and viewing and paying bills. If you'd like to use this service, please specify an Internet Password and Password Hint at this time. Please note, for security purposes, your Internet Password must be a combination of letters and numbers.

Contrasena de Internet:
Como uno de nuestros servicios, ofrecemos un portal en línea para la administración de cuentas y la visualización y el pago de facturas. Si desea utilizar este servicio, especifique una contraseña de Internet y una sugerencia de contraseña en este momento. Tenga en cuenta, por razones de seguridad, que su contraseña de Internet debe ser una combinación de letras y números.

Internet Password:  
Confirm Internet Password:  
Password Hint:

Existing or Previous Service:
Have you ever had service with us before?

Servicio Existente y Anterior Servicio existente o anterior
¿Alguna vez ha tenido servicio con nosotros antes?

Número de cuenta
Account Number:
Fee & Deposit Information:
A $25.00 membership fee is required from all applicants. Based on the results of a credit check, a deposit may also be required. Once your account is created in our system, you will receive an email including the total amount due on your new account.

Tarifas e informacion de deposito:
Se requiere una cuota de membresía de $ 25.00 de todos los solicitantes. Sobre la base de los resultados de una verificación de crédito, un depósito también puede ser necesario. Una vez que su cuenta se haya creado en nuestro sistema, recibirá un correo electrónico que incluirá el importe total adeudado en su nueva cuenta.

Membership Fee:  

Emergency Contact Not At This Residence:
Address:  *
Home Phone:  *
Cell Phone:  
Landlord Name and Number:
*required if renting
Do you:   *
Please select preferred Billing Method:   *
The undersigned hereby applies for membership in Kosciusko REMC and agrees to the following terms and conditions.

El firmante por la presente aplica para afiliacion en Kosciusko REMC, y esta se acuerdo en lo siguiente terms and conditions.

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

Entiendo que marcar esta casilla y escribir mi nombre en el campo proporcionado a continuación es mi firma electrónica.

  Applicant Name: Nombre del solicitante:     *