Application For Membership and Electric Service

To start residential or business service, complete the application below.  If you have any questions regarding new service please send an email to  

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

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Applicant Information:
First Name:
Last Name:   *
Middle Initial:  
Social Security Number:--  *
Drivers License Number:  *
Type of Heat?
(propane/natural gas, electric, wood or other)

Mailing Address:
Please enter the address where bills should be sent:
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address:   *
Service Type (Construction Required or Existing Service):   *
Additional Authorized Contact(s):
(name, relationship, address, phone, email)
*persons listed will have authorization to request and receive account information
E-mail:  *
Confirm E-mail:  *
Best Contact Phone:--   *
Cell Phone:--  
Spouse Information:
Social Security Number:-- 
Previous Address:
City, State:  

Online Access:
We offer a portal for online bill payment and account management. Just visit!  If you would like access to your account online, please create a password and password hint below. 

Also download our free mobile app! 
Internet Password:  
Confirm Internet Password:  
Password Hint:

Membership Fee:  

Do you want this to be a Prepay account?
(indicate yes or no)
Property Owner Information:*required if renting
Street Address:  
City, State:  
Phone Number:  
To confirm, please select rent or own for the service location:   *
Do you want to participate in Community Fund?  
Please select preferred Billing Method:   *
The undersigned (hereinafter called the “Applicant”) hereby applies for membership in and agrees to purchase energy from Mid-Ohio Energy Cooperative, Inc., (hereinafter called the “Cooperative”), upon the following terms and conditions. I also agree to the Prepay Terms and Conditions, which are applicable to me if I have indicated I wish to have a prepay account on the application above or decide to have a prepay account with Mid-Ohio Energy Cooperative, Inc.
I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *