Amicalola Electric
Membership Corporation
Account
# ________________
544 Hwy 515
South
Fees:
____________________
706-253-5200
Commercial Service Application
Name of Business:
________________________________________
(Exact incorporation
name)
DBA: (if applicable)
_____________________________________________________
Type Organization:_________________________________________
(Corp, LLC, Partnership,
Sole Ownership, Gov’t Agency,
Other)
Owner(s), Partners or
Officers Name & Title:
________________________________
______________________________________________________________________
______________________________________________________________________
Type Business:
________________________Business size: (sq. ft.
)_____________
(Office, Restaurant, Retail,
Manufacturer, Distributor, Other)
Date Business Started:
__________________________________________________
Sales Tax Status:(Indicate exempt or non
exempt)____________________________
NAICS:
____________________DUNS:
_____________________________________
Federal ID #:
_______________ State of Incorporation:
________________________
Address Where Service Is To
Be Connected: ________________________________
______________________________________________________________________
City/State/Zip
__________________________________________________________
Mailing Address if different
than Service Address: ___________________________
______________________________________________________________________
City/State/Zip
__________________________________________________________
Contact Information:
Business Number: ______________________________
Other:
_________________________________________
Contact Person:
________________________________
Daytime Telephone Number:
______________________
Email Address:
_________________________________
Applicant acknowledges
that at the time this application was signed, a copy of the Bylaws, Rules and
Regulations and the Statement of Nondiscrimination was made
available.
In the event this account
is delinquent and collected through an attorney or a collection agency,
additional collection fees and interest will be charged to your account. Applicant acknowledges and consents to
the Cooperative receiving and obtaining applicant’s credit
report.
_______________________________________________
(Name of Corporation)
_______________________________________________
(Principal Officer)
(Date)
(Corporate
SEAL)