Upgrade/Downgrade Service Agreement Complete this form, read and sign, then submit the form by clicking the "Submit Form" button at bottom. Fields with * are required fields. Account Information *Member Name: Meter Number: *Primary Phone: *Is the primary a mobile phone?: Yes No Secondary Phone: Is the secondary a mobile phone?: Yes No Please note that by providing your cell phone number, you are giving the cooperative permission to text you about important, account-related information (outages, balance due, etc.) and in emergency situations. *Email: *Preferred Method of Communication: Phone Email Text Service Location *Location inside the city limits?: Yes No *County: Atascosa Brooks Dimmit Duval Edwards Frio Jim Hogg Kinney LaSalle McMullen Medina Real Starr Uvalde Webb Zapata Zavala If located in Dimmit, Kinney, LaSalle, Starr, Webb, or Zavala counties: A Certificate of Compliance must be on file before your application can be processed. You can obtain your Certificate by contacting the appropriate county planning department. If the location is in the city limits for any of the above counties, city permits may also be required. Gate Code: Predominant Use of Electricity *Select Predominant Use of Electricity: Residential Farm or Ranch Business Commercial or Industrial Other For Residential, Complete this Section. Residential Type: Primary Residence Occupied Full Time Weekend/Vacation Home Other Personal Residential Use For Other Personal Residential Use, indicate use. Example: residential water well, personal shed, personal hunting cabin, gate, etc. Other Residential Use: For Farm or Ranch Business, Complete this Section. Type of Farm or Ranch Use: Irrigation Pivot Stock Water Well Farm Building Other Farm Use If Irrigation, Pivot or Water Well then indicate HP: If Farm Building, indicate use: If Other Farm Use, indicate use: For Commercial or Industrial Use, Complete this Section. Indicate type of Commercial Use. Example: office, pump jack, manufacturing plant, etc. Commercial Use: For Other Use, complete this section. Indicate Other Use. For example church, school, cemetery, etc. Other Use: *Construction Details (describe construction project): New Construction Information Metering requirements vary based on type of service. You should provide a suitable and easily accessible location including: (1) sufficient and proper space for installation of meters and other apparatus of the Cooperative, (2) meter loop, (3) safety service switches when required and (4) an adequate anchor for service drops. We recommend you use a licensed electrician for the installation of the meter loop. Wiring specifications may be found here. Construction Details *Main Disconnect (Amps) New: Main Disconnect (Amps) Existing: If primary meter, enter PME. New Meter Location: Meter Pole Main Residence or Building Please indicate if you want information on purchasing a meter loop from Medina EC? (200 amp only) For your convenience, Medina EC sells 200 amp meter loops for $680-780* plus applicable taxes. If you would like more information about purchasing your meter loop from the cooperative, indicate here or discuss it with the line designer during the site visit to your location. *Pricing is determined by the size of meter pole and is subject to change without notice. Do you want info on a meter loop?: Yes No Service Voltage and Main Disconnect Size Primary: Overhead Underground Secondary: Overhead Underground Secondary Voltage: 120/240 1 Phase 3 Wire 240/480 1 Phase 3 Wire 120/208 3 Phase 4 Wire Wye 277/480 3 Phase 4 Wire Wye Note:120/208 3 Phase 4 Wire Wye - Service is limited to 100kVA transformer on the pole.277/480 3 Phase 4 Wire Wye - Service is limited to three (3) 100kVA transformers on the pole. Electrician Information Electrician/Engineer Name: Phone Number: Email Address: License Number: AUTHORITY. Member represents and warrants that each representative of Member executing this Agreement is duly authorized to do so. By executing below, the natural person(s) who executes this Agreement on behalf of Member represents and warrants that he or she has the authority to bind said entity. Click here to draw your signature. Member Signature With your mouse, draw your signature. Then click Finish. Date: (MM/DD/YYYY) Click here to draw your signature. Commercial / Corporate Signature Authority With your mouse, draw your signature. Then click Finish. Name of Person Signing: Commercial/Corporate Title: Date: (MM/DD/YYYY)If Commercial / Corporate signature is other than President, Vice President, Partner, or Owner, proof of signature authority may be required.
