Application For Membership

To start residential or commercial/business service, complete the application below.  Click here for Membership Information.  If you have any questions regarding new service please send an email to onlinerequests@mitchellemc.com.  

Note: All fields with the asterisk (*) are required.

*Please do not submit new service requests longer than 45 days prior to desired service connection date.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Applicant Information:
Legal First Name:		   *
Legal Last Name:   *
Legal Middle Initial:  
Social Security No.:--  *
Drivers License No.:  *
Birth Date:    
Employer:  
Employer Street Address:  
Employer City, State:  
Employer Zip Code:  

Mailing Address:
Please enter the address where bills should be sent:
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address:
Physical 911 Address:
Service Address:  
City and County; Within the City Limits?   *
E-mail:  *
Confirm E-mail:  *
Home Phone:--   *
Cell Phone:--   *
Employer Phone:--   
Spouse Information:
Legal Name:		 
Social Security No.:-- 
Drivers License No.:  
Birth Date:    
Employer:  
Employer Street Address:  
Employer City, State:  
Employer Zip Code:  

Online Access:
We offer a portal for online bill payment and account management. If you would like access to your account online, please create a password and password hint below. Please note passwords must be a combination of letters and numbers.
Internet Password:  
Confirm Internet Password:  
Password Hint:

Existing/Previous Service:
Have you had service with us before?    
Account Number:

Connect Fee:  

Do you want this to be a Prepay account?
(indicate yes or no)		  *
Do you rent or own the service location?   *
Participate in Operation Round Up?   *
Please select preferred Billing Method:   *
 
I agree to abide by the Membership Agreement and the procedures, Policies, bylaws, service rules and regulations and the Prepay Terms (when applicable) of the Corporation. I also agree and understand that Mitchell EMC will be sending account related correspondence via text, email and voice.
I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *