Piedmont Electric Membership Corporation

This service is designed for new members who are moving into a residence with existing electric service. If you are establishing service at a location that does not have electric power in place, such as new construction, please contact Piedmont EMC at 919.732.2123, or toll-free NC only 1.800.222.3107. In addition, if you require service within the next 2 days (excluding weekends and holidays), we ask you to contact us at the telephone numbers listed above.

New applicants are required to pay a $5.00 membership and a deposit to receive electric service. The deposit requirement can be waived if we receive one of the following:

If a deposit is collected for your new account, it will be held a minimum of 12 months (unless service is terminated prior to then). Deposits are released once your bill has been paid on time for a minimum of 12 months with 2 or fewer delinquent bills. The deposit accrues interest after 90 days. Deposits are refunded as a credit against your bill.

At the end of the application form you will have an opportunity to provide additional information about your request or to ask other questions regarding your new service. Please print out a copy of your completed application form for your records.

First Name:
Last Name:
Middle Initial:
Suffix:
Social Security #:
Day Time Phone #:
Evening Phone #:
Driver License #:
Email Address:
Customer Validation Code:
*This Code will be used for customer verification in case we need to contact each other by phone. You may use any word you like. ie, Mother's Maiden Name, etc.

Requested Service Date:	Month	Day	Year
* Service can be connected on any weekday, Monday through Friday, excluding holidays.

I will need service at:
Address 1:
Address 2:
City:
State:
Zip:

Billing Address (if different from above)
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip:

Please Check one of the following:

Please check my credit through credit services.
(Current address information required)

		My Current Address
	Address 1:
	Address 2:
	City:
	State:
	Zip:

I will provide a letter of credit from my previous electric utility to qualify for service.
The reference will come from:

I will pay a security deposit. Please provide to me the amount required.

Please contact me about having a guarantor on this account.

Additional notes and/or comments

2500 N.C. 86 South, Post Office Drawer 1179
Hillsborough, N.C. 27278-1179
919.732.2123
1.800.222.3107 (NC only)

Fax Number
919.732.9978