Please complete this form to request new service. If you are establishing service at a location that does not have electric power in place, such as a new construction, please indicate this in the field area provided below or call an engineering and operations specialist at 1.800.672.8212.  Service Requests are processed from 8a.m. to 5p.m. Monday through Friday. We need a minimum of 24 hours notice before service can be established. If you have any questions, or need service immediately, please contact a member service specialist at 1.800.672.8212.

If you are renting or leasing your property, a rental agreement is required and service will not be processed until the documentation is received. Please fax documentation to 336.626.1551. In certain circumstances additional identification may be required.  In the comments section of the application form, you will have an opportunity to provide additional information about your request or to ask other questions regarding your new service. 

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


Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Member Information:
First Name:		   *
Last Name:   *
Middle Initial:   *
Social Security #:--  *
Driver's License #:  *
License State:  
Birth Date:
*must be 18 for service in your name		    
Employer:  

Mailing Address:
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address:
Physical 911 Address of Location
Service Address:   *
City, State, Zip Code/Additional Comments:  
E-mail:  *
Confirm E-mail:  *
Home Phone:
*if home and cell are the same, please enter in both field areas to ensure accurate correspondence		--   *
Cell Phone:--   *

Online Account Access:
Make payments or access your account anytime at Randolphemc.com or on the Randolph EMC Mobile App. Please create a password below using a combination of letters and numbers. Your username is the email address listed above.
Internet Password:  
Confirm Internet Password:  
Password Hint:

New Construction:
Is this New Construction?

    
Account Number:


Would you like this to be a FlexPay Account? (yes or no)  *
Is there an existing outdoor light at the location? (yes or no)  *
If yes, do you want to keep the Outdoor Light? (yes or no)
Note: There are monthly charges associated with this request.		  
What fuel source do you use for heat?  *
What fuel source do you use for water heating?  *
Do you own or rent the service location?   *
Enroll in People Helping People?  
Please select your preferred billing method:  
 
I have read and agree to the Service Rules & Regulations , bylaws, and FlexPay Terms of Service (if applicable) of Randolph EMC. By submitting this application request, I also agree that a credit check may be submitted, if necessary, to determine if a security deposit is required. I also give Randolph EMC express consent to send SMS text alerts to inform me of account activity. If your mobile number changes, it is important that you contact Randolph EMC to update the information. 
I understand that checking this box and typing my name in the field provided below is my electronic signature
  Applicant Name:
First, Middle and Last are required     *