Application for Membership and Service

Please complete this application to apply for new service. If you wish to disconnect your Carroll EMC service, please click here. If you have any questions regarding setting up new service, please contact Member Services during normal business hours at (770) 832-3552. Same day service may be available at some locations.

If you are applying for Temporary Service, Renovating/Remodeling or starting New Construction, please contact Member Services at 770-832-3552.

All fields with the asterisk (*) are required.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Legal First Name:   *
Legal Last Name:   *
Legal Middle Initial:  
SSN:-  -   *
Who else is authorized on this account?  
Last 4 digits of SSN for authorized person(s):  

Mailing Address:
Please enter the address where bills should be sent. Include Apt #, Suite # or Building # to line one, if applicable.
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address:

Service Address:   *
Service Type (Construction Required or Existing Service):   *
Comments:  
E-mail:  *
Confirm E-mail:  *
Phone Numbers Associated with Account:
Primary Phone:		-  -    *
Cell Phone:-  -   
Other Phone:-  -     
Spouse Name: 
Spouse SSN:-  -   

Online Access:
As one of our services, we provide an online application for viewing and paying bills. If you would like to use this service, please specify an Internet Password and Password Hint at this time. Please note that the Internet Password must be at least four characters in length.
Internet Password:  *
Confirm Internet Password:  
Password Hint:

Existing Service:
Have you ever had service with us before?    

Account Number:

Fee & Deposit Information:
All new applicants are required to pay a $15.00 membership fee and a $20.00 account service charge. These fees may be billed or the applicant may be required to pay before connection of service, pending a credit check. Based on the results of a credit check, a security deposit may also be required. When your account is created, you will receive an e-mail with the total amount due on your new account, including the deposit amount, if applicable. Please note: PrePay accounts require a minimum of $50 credit for daily usage at initial account set up.


Membership Fee:  
Account Service Charge:  

Is there an outside yard light at this location?
(indicate Yes, No or I Don't Know):		  *
If yes, do you want to continue service to this outdoor light?
(indicate Yes or No):		  
Please select preferred Billing Method:   *
 
I accept and comply with the Bylaw Terms & Conditions, Service Rules & Regulations, Conditions of Membership and PrePay Terms of Service (if applicable). By checking this box, I am electronically signing my application for service. I understand that a credit/identity check will be performed on all applicants. Any past due amounts to Carroll EMC must be paid in full before service can be established. If you've never had service with us before, you may be required to apply in person at one of our offices. Applicant shall be enrolled in Operation Round Up. To opt out of this program contact member.services@carrollemc.com

I understand that checking this box and typing my name in the field provided below is my electronic signature. Your signature gives prior express written consent to receive automated telephone calls and text messages (if applicable) from the Cooperative to any number you have provided.
  Applicant Name:     *