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?:
*Location:
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):
Date: (MM/DD/YYYY)



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