Agreement for Construction of Power Line - Subdivision Members should complete and then sign the agreement below for construction of a power line in a subdivision or backbone. *Applicant Name: Member Number: Subdivision Name (if applicable): *Physical Address: *City: *State: *Zip Code: Billing Address: City: State: Zip Code: *Primary Phone: Secondary Phone: *Email Address: If you choose not to provide your social security number, you will have to visit one of our offices and present your driver's license in person so your identity can be verified. Your social security number will be used to do an online identity check and to determine certain credit requirements. SSN (Federal Tax ID No. for business): Load Requirements Please indicate if you want overhead or underground service. *Overhead or Underground?: Overhead Underground *Location: Atascosa Brooks Dimmit Duval Edwards Frio Jim Hogg Kinney LaSalle McMullen Medina Real Starr Uvalde Webb Zapata Zavala Is the subdivision inside city limits? *Within City Limits?: Yes No If Yes, type the name of that city below. Subdivision City: Number of Lots: Average Lot Size: Typical Home Size planned, if known: Unknown Less than 1500 sq ft 1501 to 3000 sq ft 3001 to 6000 sq ft 6001 sq ft or larger Is this part of a multiphase project?: Yes, this is phase one of a multiphase project. Yes, Medina EC has already designed other phases. No, this is not a multiphase project. Attach a copy of the Plat for the project. This is required before a site visit can be scheduled. Upload Plat: It is understood that the developer(s) will be required to remit the construction estimate as aid to construction for a subdivision or backbone power line to be built. It is understood that all poles and guy wires will be placed so as to form the least possible interference, so long as it does not materially increase the cost of construction. It is understood that all facilities, installed in said subdivision or backbone, shall remain the property of Medina Electric Cooperative, Inc. Click here to draw your signature. Signature With your mouse, draw your signature. Then click Finish. Printed Name: Title: For a commercial corporation, signature authority (title) must be indicated. If signature is that other than President, Vice President or Owner, Power of Attorney must be attached. Power of Attorney (if applicable):
