Current Service Address Information Secondary Customer Information (Optional) Security Deposit Privacy of Information Pre-Authorized Payments Form Complete Service Address Service Address Enter the service address in which you are moving into. Unit #/P.O. Box City/Town State/Province - Select ---- Canada Provinces ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon--- US Provinces ---AlabamaAlaskaAmerican SamoaArizona ArkansasArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)CaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Country - Select -CanadaUnited States If you are the tenant of the service address, please advise us of the landlord's name. If applicable - Landlord Name Date of Possession Any Comment Legal Document of Date Of Possession One file only.256 MB limit.Allowed types: pdf, doc, docx. Primary Customer Information First Name Last Name The Mailing Address is the same as my Service Address. Mailing Address Mailing Address Unit #/P.O. Box City/Town State/Province - None ---- Canada Provinces ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon--- US Provinces ---AlabamaAlaskaAmerican SamoaArizona ArkansasArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)CaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Country - None -CanadaUnited States Phone Number E-Mail Address Date of Birth Driver's License Current Employer If you would like to opt out of e-billing immediately, please check this box. I hereby request E.L.K. Energy Inc. to supply electrical service to the premises at the above address. I hereby further agree to pay for service at the authorized rates from the date on which the service is connected, subject to change from time to time. Statements are payable at our office on or before the due date. All accounts not paid by the due date are subject to a late payment charge, as well as collection action including disconnection and payment of a reconnection fee. I understand that in the event that this electrical service requires connection that the connection will only occur during regular business hours. No guarantee of connection date will be made, all connections will be made on a best effort basis. I acknowledge and understand that a copy of E.L.K Energy’s (E.L.K.) Conditions of Service is accessible for my review at the customer service counter at E.L.K. Energy Inc., 172 Forest Avenue, Essex Ontario N8M 3E4 as well as on E.L.K’s website at www.elkenergy.com. To switch from Time-of-Use to Tiered prices, you must notify E.L.K. Energy Inc by completing an election form found on our website at www.elkenergy.com Signature Sign above Date
