UEC Membership Application
Application to start service with United Electric Cooperative.
Applicant certifies that the one box marked is the predominant use of electricity. If energy purchased results in a sales tax liability due to use other than stated, the Applicant assumes responsibility for remitting such tax due directly to the Director, Missouri Department of Revenue.
Household
House Well
Rental House
Grain Dryer or Bin
Barn
Well
Cabin
Camper
Other
Date Effective
Date
Do you own or rent the property?
*
Own
Rent
Member Information
Member Full Name
*
First Name
Last Name
Joint Member Full Name (Leave Blank if No Joint Member)
First Name
Last Name
Physical Address of Service
*
Street Address
City
State
Zip
Mailing Address (If different than service address)
Street Address
City
State
Zip
Primary Phone Number
*
Email Address
*
By entering your email address you agree to receive emails from United Electric Cooperative.
Emergency Contact
*
Emergency Contact Number
*
Please enter a valid phone number.
Landlord Name (If renting property)
Landlord Phone Number
Please enter a valid phone number.
Member Social Security Number or Federal Tax ID
*
This field is used only for credit verification purposes to determine required deposits. SSN data is encrypted and not stored on UEC website.
Joint Member Social Security Number or Federal Tax ID (If applicable)
This field is used only for credit verification purposes to determine required deposits. SSN data is encrypted and not stored on UEC website.
Notes to Member Services Representative.
Drivers License or State Issued ID
*
I agree to the
terms & conditions
and understand a that a Credit Reporting Agency will be used to verify applicant.
*
I Agree
Date
*
Signature
*
Clear
Please verify that you are human
*
