Start or Stop Service

Name(Required)

First Middle Initial Last

Account(Required)

Joint

Single

Service Address(Required)

Street Address Address Line 2 City State ZIP Code

Billing Address(Required)

Same as previous

Street Address Address Line 2 City State ZIP Code

Social Security Number(Required)

Date of Birth (mm/dd/yyyy)(Required)

Must be at least age 18

Phone(Required)

Email(Required)

Employer

Employer Phone

Spouse or Authorized Contact

Authorized contact is someone authorized by member to receive account information only.

First Last

Social Security Number

Date of Birth (mm/dd/yyyy)

Must be at least age 18

Phone

Email

Employer

Employer Phone

Mark the box that most accurately describes the predominant use of electricity.

Residential

Commercial

Irrigation

Organization

Consent(Required)

I hereby authorize the Cooperative to make any investigation of my personal history and financial and credit record through any investigative or credit agencies or bureaus chosen by the Cooperative. I understand the credit report obtained and considered will comply with the provisions of the Fair Credit Reporting Act.

I am interested in information regarding:

Auto Debit

Online Bill Pay

Budget Billing

Member Consent(Required)

I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.

In applying for membership service with Barton County Electric Cooperative, I am applying to receive electric service at the location described above. I agree to conform to and abide by the bylaws and regulations as provided by the Board of Directors of the Cooperative, as now exists or as may hereafter be adopted.

My signature below authorizes a deduction of not less than $2 and not more than $4 annually from the Cooperative's equity as payment for my subscription to the monthly publication, Rural Missouri.

Member Electronic Signature (Full Name)(Required)

Start or Stop Service

Moving or Closing an Account

Starting New Service

Membership Application