Name(Required) First Last Activation Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone(Required)Email(Required) Service Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Social Security Number(Required) Driver License Number(Required) Employer(Required) Employer Phone(Required)Spouse's Name** This is required if the secondary person is listed on proof of ownership or lease** Spouse's Social Security Number** This is required if the secondary person is listed on proof of ownership or lease** Name & Social Security Numbers of Occupants Over 18Rental Property?(Required) Yes No Owner of Property(Required) First Last Is this your Primary Residence?(Required) Yes No If not, describe. The undersigned hereby makes application for electrical service at the above address and agrees to pay for said service as measured by the System's meters, according to rates applicable to each billing. It is further agreed and understood that this document will apply for all future transfers of said service to this customer. The Applicant(s) also agrees to make a one time initial minimum payment of $100 which consists of a $25 application fee, a $15 connection fee and a $60 of prepaid electric usage. The Applicant(s) understands that this application is for Prepaid Electric only. The Applicant(s) also agrees, if applicable, to man any and all old debt to a debt recovery plan of 25% of all future payment until the old debt is paid in full. If the Applicant(s) should desire to transfer to a traditional postpay electric service, they will be subject to a security deposit as required by his/her credit history and understands any old debt will have to be paid in full before being transferred to a traditional postpay electric service. The Applicant(s) shall be responsible for all current consumed upon the premises from date of installation, and shall permit authorized agents of the System free access to the premises of the consumer for the purpose of inspecting, reading, examining, repairing or removing meter or other property, and maintaining right of way which includes vegetation management. The Applicant(s) further agrees that in the event they fail to pay a legitimate account, they will pay reasonable attorney's fees incurred by Dickson Electric System for collection of the delinquent account. The Applicant(s) understand and agree that Dickson Electric System may be limited in the amount of power that it can furnish due to limitation made by the wholesale power supplier. The Applicant(s) further understand and agree that the Dickson Electric System on some occasions may be unable to furnish electric power due to unforeseen and unavoidable circumstances. The undersigned herby certifies that they at the present time do not owe Dickson Electric System for prior service and further certifies that this application is their bonafide application and not submitted in conjunction with or on behalf of another person who has had electric service terminated by the System for failure to pay. They further certify that in the event this is a false application, they understand and agree that the electric service may be terminated immediately. Dickson Electric System does not discriminate on the basis of race, color, sex, age, handicap, religion, or nation origin. (Required) I hereby authorize Dickson Electric System to review my credit record and to make any necessary investigation of my credit transactions. In consideration of its undertaking to make such an investigation, I authorize any business or organization to give full information and records about me.Applicant's Electronic Signature (Full Name)(Required) Driver's License Drop files here or Select files Max. file size: 300 MB. Proof of Ownership - Proof of Ownership (Closing Disclosure, Settlement Statement, Purchase and Sales Agreement or Property Deed) - Lease (First page and Signature page) Drop files here or Select files Max. file size: 300 MB. CommentsThis field is for validation purposes and should be left unchanged. Application For Prepaid Electric Service Name(Required) First Last Activation Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone(Required)Email(Required) Service Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Social Security Number(Required) Driver License Number(Required) Employer(Required) Employer Phone(Required)Spouse's Name** This is required if the secondary person is listed on proof of ownership or lease** Spouse's Social Security Number** This is required if the secondary person is listed on proof of ownership or lease** Name & Social Security Numbers of Occupants Over 18Rental Property?(Required) Yes No Owner of Property(Required) First Last Is this your Primary Residence?(Required) Yes No If not, describe. The undersigned hereby makes application for electrical service at the above address and agrees to pay for said service as measured by the System’s meters, according to rates applicable to each billing. It is further agreed and understood that this document will apply for all future transfers of said service to this customer. The Applicant(s) also agrees to make a one time initial minimum payment of $100 which consists of a $25 application fee, a $15 connection fee and a $60 of prepaid electric usage. The Applicant(s) understands that this application is for Prepaid Electric only. The Applicant(s) also agrees, if applicable, to man any and all old debt to a debt recovery plan of 25% of all future payment until the old debt is paid in full. If the Applicant(s) should desire to transfer to a traditional postpay electric service, they will be subject to a security deposit as required by his/her credit history and understands any old debt will have to be paid in full before being transferred to a traditional postpay electric service. The Applicant(s) shall be responsible for all current consumed upon the premises from date of installation, and shall permit authorized agents of the System free access to the premises of the consumer for the purpose of inspecting, reading, examining, repairing or removing meter or other property, and maintaining right of way which includes vegetation management. The Applicant(s) further agrees that in the event they fail to pay a legitimate account, they will pay reasonable attorney’s fees incurred by Dickson Electric System for collection of the delinquent account. The Applicant(s) understand and agree that Dickson Electric System may be limited in the amount of power that it can furnish due to limitation made by the wholesale power supplier. The Applicant(s) further understand and agree that the Dickson Electric System on some occasions may be unable to furnish electric power due to unforeseen and unavoidable circumstances. The undersigned herby certifies that they at the present time do not owe Dickson Electric System for prior service and further certifies that this application is their bonafide application and not submitted in conjunction with or on behalf of another person who has had electric service terminated by the System for failure to pay. They further certify that in the event this is a false application, they understand and agree that the electric service may be terminated immediately. Dickson Electric System does not discriminate on the basis of race, color, sex, age, handicap, religion, or nation origin. (Required) I hereby authorize Dickson Electric System to review my credit record and to make any necessary investigation of my credit transactions. In consideration of its undertaking to make such an investigation, I authorize any business or organization to give full information and records about me.Applicant's Electronic Signature (Full Name)(Required) Driver's License Drop files here or Select files Max. file size: 300 MB. Proof of Ownership – Proof of Ownership (Closing Disclosure, Settlement Statement, Purchase and Sales Agreement or Property Deed) – Lease (First page and Signature page) Drop files here or Select files Max. file size: 300 MB. EmailThis field is for validation purposes and should be left unchanged.
