Member Application

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Application Information

Application Date:

Date Service Is To Be Connected/Transferred:

Service Address

Service Address 2

City/Town

State/Province

ZIP/Postal Code

Applicant Information

Name of Primary Applicant:

SSN:

Driver's License or ID#:

State:

Mailing Address

Mailing Address 2

City/Town

State/Province

ZIP/Postal Code

Telephone #:

Cell Phone #:

Work Phone #:

Previous Address

Previous Address 2

City/Town

State/Province

ZIP/Postal Code

Employer (If Self, Please Explain)

Job Title:

Employer Address

Employer Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Marital Status:

Single

Married

Divorced

Widow

Name and Address of Relative Not Living With You

Bank & Branch:

Home:

Rent

Own

Landlord:

Beneficiary

Please list your beneficiary of Capital Credits or any other refunds due upon Member's death.

Spouse Name:

Name:

Relationship:

Beneficiary Phone #:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Additional Applicant Information (if applicable)

Additional Applicant Name:

Relationship

Spouse

Reg. Partner

Co-signer

SSN:

Driver's License or ID#:

Telephone #:

Cell Phone #:

Work Phone #:

Job Title

Employer (If Self, Please Explain)

ID Required For Spouse (if applicable)

Drivers License

Passport (serves as both)

Birth Certificate

Upload ID For Spouse

One file only.
20 MB limit.
Allowed types: gif jpg jpeg png.

Name and Address of Relative Not Living With You

Have you or the additional applicant ever had service with Mt. Wheeler Power before?

Yes

If yes, what name was the account in?

Is anyone in the home on life support?

Yes

If yes, what is their name and relationship to you?

Signatures

Everything I (we) have stated on this application is true and correct. I (we) authorize Mt. Wheeler Power to verify my (our) credit and employment history at any time it deems necessary. I (we) agree to be bound by the Cooperative’s Articles of Incorporation, Bylaws, and Rules and Regulations, as currently adopted and as may be amended in the future. I (we) also certify that all forms of identification provided with this application are valid, authentic, and belong to the applicant(s) listed.

Applicant Signature

Sign above

Co-Applicant Signature

Sign above