Application for Membership

An Application for Membership In and For Electric Service is required from all Members.  The below application can be used to apply for Residential or Commercial service.  If you have any questions, please feel free to contact our office at 252-209-2236 or 800-433-2236 and one of our customer service representatives will assist you.   

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

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

Mailing 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):   *
Comments or Directions if New Construction:  
E-mail:  *
Confirm E-mail:  *
Home Phone:--   *
Cell Phone:--  
Work Phone:--   
Co Applicant Information:
Name:		 
SSN:-- 
Driver's License:  
License State:  
Birth Date:    
Employer:  

Online Account Access:
We offer a web portal and mobile app for access to your payment options, account management and easy access to your ebill. If you would like to access your account online, please create a password and password hint below. Please note, for security purposes, the password must be a combination of numbers and letters.
Password:  
Confirm Internet Password:  
Password Hint:

Existing or Previous Service:
Have you ever had service with us before?    
Account Number:
Fee and Deposit Information:
Each Service is required to pay Roanoke Electric Cooperative the sum of $10.00 as a meter deposit. Other deposits and membership fees may apply. When your account is officially created in our system, you will receive an email with the total amount due on your new account.

Other Deposit:  
Connect Charge:  
Sales Tax:  

Do you rent or own the service location?  
Roanoke Electric Cooperative provides assistance to many area organizations through its member funded Operation Round Up program.
As a member you're signed up to have your electric bill rounded up to the next highest even dollar to support the program. If you don't want to participate in this program, please select No from the dropdown box.		  
Please select your preferred Billing Method:  
 
I hereby apply for electric service in accordance with the Terms and Conditions of this application. By submitting this application request, I also agree that a credit check may be submitted, if necessary, to determine if a security deposit is required. A one time $5.00 membership fee applies.
I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *