NODAK ELECTRIC COOPERATIVE, INC.

RESIDENTIAL APPLICATION FOR MEMBERSHIP & ELECTRIC SERVICE

Please fill out form below and a member service representative will contact you to confirm your application.

If you need assistance, please call 1-800-732-4373 or 1-701-746-4461.

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APPLICATION SUBMISSION DATE

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APPLICATION SUBMISSION TIME

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APPLICATION TYPE*

I am applying for electric service to an existing home (apartment, house, etc.)
I am applying for electric service for construction of a new house and I am not a builder or contractor.

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Please indicate Nodak engineering representative you are working with on this project: (Select below)*

PROPERTY INFORMATION

Service Address*

Unit/Apt./Suite

Service Description*

Meter Number (if known)

City*

State*

Zip Code*

Move-In / Close Date*

Do you own or rent/lease the service address listed above?*

Own
Rent / Lease
Contract for Deed

Owner/Managment Company

Phone

Address

BILLING ADDRESS (WHERE YOU WISH TO HAVE YOUR ELECTRIC BILL MAILED)

Is the billing address the same as the service address?*

Yes
No

Billing Address*

City*

State*

Zip Code*

PREVIOUS ADDRESS

Do you currently have an active service with Nodak?*

Yes
No

What is your current address serviced by Nodak?

Service Address Address Line 2 City State ZIP Code

Do you wish to have your current service disconnected?*

Yes
No

Attention: Since you wish to have your current service disconnected you will be directed to the service disconnect form upon completion of the current form.

PRIMARY MEMBER INFORMATION

Have you had an account with us in the past?*

Yes
No

What was your previous address that was serviced by Nodak?

Service Address Address Line 2 City State ZIP Code

First Name*

Middle Name*

Last Name*

Primary Phone*

Is this a mobile phone?

Additional Phone

Is this a mobile phone?

Email*

Social Security Number*

Date of Birth*

Do you have a valid drivers license?

Yes
No

Drivers License State (Select One)*

Drivers License Number*

ADDING JOINT MEMBER

If primary member desires to add a joint membership, please contact our office after completing application.

ACCOUNT SHARING INFORMATION

If primary member wishes for Nodak Electric Cooperative, Inc. to share account information with an individual (such as roommate, parent, or landlord), please indicate name and contact information below.

Name

First Middle Last

Phone

Birthdate (used to identify caller)

Email

EMERGENCY CONTACT

NOT LIVING WITH YOU

Name*

First Last

Relation*

Phone*

OPERATION ROUND-UP

Operation Round-Up is a program where participating member’s bills are rounded up to the next dollar amount and the difference, averaging approximately $6.00 annually, is donated to worthy causes as dictated by a seven-member board quarterly. If you wish not to participate in the program, please indicate below:

I do not wish to help those in need by declining to contribute towards the Operation Round Up program

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Operation Round-up Opt-in

SECURITY DEPOSIT INFORMATION

A security deposit is required for all services and due immediately to receive electricity. Deposits for apartment occupants are $100 to $150, for new constructed services $200 to $300, and all other deposits are calculated as two-times the average bill, as determined by Cooperative. The deposit will be returned to applicant after 12 months of continuous good credit with cooperative. Deposits may be waived if applicant signs up for bank draft withdrawal through Nodak’s Automatic Payment Plan, upon receipt of a satisfactory credit report, has a 12-month favorable credit reference from applicant’s current power supplier, or has an existing account in good standing.

PAYMENT AND WAIVER OPTION FOR DEPOSIT (Select one)*

**Clicking on an option will reveal details**

Enroll in Automatic Payment Plan
Allow Credit Check
Pay Deposit
Provide 12 month favorable credit history from applicant's current power supplier

**Automatic Payment Plan allows you to pay your electric bill without writing a check. Participants will still receive a monthly statement and payment will be automatically withdrawn from your bank account on or near the 25th of each month.**

**A member service representative will contact you with instructions**

Financial Institution*

Routing Number*

Account Number*

Account Type*

**NODAK ELECTRIC COOPERATIVE, INC. WILL ACQUIRE MY CREDIT REPORT (SOFT CREDIT PULL) FOR THE PURPOSE OF DETERMINING IF DEPOSIT IS REQUIRED.**

TERMS AND CONDITIONS

Nodak Terms ________________ Applicant hereby applies for membership and agrees to purchase electric energy from Nodak Electric Cooperative, Inc., upon the following terms and conditions: 1. Applicant will pay monthly rates in accordance with the bylaws of the Cooperative. 2. Applicant will comply with and be bound by the provisions of the articles of incorporation and bylaws of the Cooperative, and such rules and regulations as may from time to time be adopted by the Cooperative. A copy of Nodak’s articles of incorporation and bylaws are available upon request or at www.nodakelectric.com. 3. Applicant will pay the Cooperative a nonrefundable, non-transferable processing fee for each main meter location. 4. Any cosigner for the Applicant agrees to absolutely guaranty payment to Cooperative of any indebtedness owing should the Applicant default in the performance of any of the terms of his/her membership. Such guaranty by the cosigner is given in consideration of Cooperative’s extending credit to the Applicant under the terms of membership and any minimum commitment contracts entered into by the Applicant with the Cooperative. 5. The Applicant will grant to the Cooperative at its request the necessary easements to serve and supply electric power to the Applicant and other Cooperative members. The Applicant grants to the Cooperative the right of access to the Applicants property for purposes of service, installation and repair of electrical facilities. The acceptance of the application by the Cooperative shall constitute an agreement between the Applicant and the Cooperative, and the contract for electric service shall continue in force. 6. Monthly invoice may include off-peak electric heating and/or outdoor rental lighting charges. By submitting application I claim the information provided is correct, that I am the applicant, and have read and fully understand the above stated Terms and Conditions. Communications Terms _______________ Applicant (member) providing mobile phone number(s) represents that: 1) the phone number(s) belong to member only; 2) he or she agrees to accept calls and/or text messages from Nodak Electric (Cooperative), its agents and contractors concerning Cooperative business matters to a mobile (cellular) number through use of an automatic telephone dialer; 3) he or she authorizes Cooperative to leave a prerecorded and/or text messages in connection with any business communication the Cooperative initiates with member.*

Nodak Terms
________________

Applicant hereby applies for membership and agrees to purchase electric energy from Nodak Electric Cooperative, Inc., upon the following terms and conditions:
1. Applicant will pay monthly rates in accordance with the bylaws of the Cooperative.
2. Applicant will comply with and be bound by the provisions of the articles of incorporation and bylaws of the Cooperative, and such rules and regulations as may from time to time be adopted by the Cooperative. A copy of Nodak’s articles of incorporation and bylaws are available upon request or at www.nodakelectric.com.
3. Applicant will pay the Cooperative a nonrefundable, non-transferable processing fee for each main meter location.
4. Any cosigner for the Applicant agrees to absolutely guaranty payment to Cooperative of any indebtedness owing should the Applicant default in the performance of any of the terms of his/her membership. Such guaranty by the cosigner is given in consideration of Cooperative’s extending credit to the Applicant under the terms of membership and any minimum commitment contracts entered into by the Applicant with the Cooperative.
5. The Applicant will grant to the Cooperative at its request the necessary easements to serve and supply electric power to the Applicant and other Cooperative members. The Applicant grants to the Cooperative the right of access to the Applicants property for purposes of service, installation and repair of electrical facilities. The acceptance of the application by the Cooperative shall constitute an agreement between the Applicant and the Cooperative, and the contract for electric service shall continue in force.
6. Monthly invoice may include off-peak electric heating and/or outdoor rental lighting charges.
By submitting application I claim the information provided is correct, that I am the applicant, and have read and fully understand the above stated Terms and Conditions.

Communications Terms
_______________

Applicant (member) providing mobile phone number(s) represents that: 1) the phone number(s) belong to member only; 2) he or she agrees to accept calls and/or text messages from Nodak Electric (Cooperative), its agents and contractors concerning Cooperative business matters to a mobile (cellular) number through use of an automatic telephone dialer; 3) he or she authorizes Cooperative to leave a prerecorded and/or text messages in connection with any business communication the Cooperative initiates with member.

I agree to the terms and conditions

Signature*

Additional Comments (optional)

By clicking the Submit button below, I understand that my identity may be checked with a credit-reporting agency to comply with the regulations under The Fair and Accurate Credit Transactions Act to help prevent Identity Theft as required by the Federal Trade Commission.

I agree

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Application for Service

NODAK ELECTRIC COOPERATIVE, INC.

RESIDENTIAL APPLICATION FOR MEMBERSHIP & ELECTRIC SERVICE

PROPERTY INFORMATION

BILLING ADDRESS (WHERE YOU WISH TO HAVE YOUR ELECTRIC BILL MAILED)

PREVIOUS ADDRESS

PRIMARY MEMBER INFORMATION

ADDING JOINT MEMBER

ACCOUNT SHARING INFORMATION

EMERGENCY CONTACT

OPERATION ROUND-UP

SECURITY DEPOSIT INFORMATION

TERMS AND CONDITIONS

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