APPLICANT:   CO-APPLICANT:
ADDRESS:
TELEPHONE NUMBER:
APPLICANT'S SOCIAL SECURITY NO:    CO-APPLICANT'S SOCIAL SECURITY NO:
DATE OF BIRTH:                                                           DATE OF BIRTH:
PLACE OF EMPLOYMENT:   PLACE OF EMPLOYMENT:
ADDRESS OF EMPLOYMENT:   ADDRESS OF EMPLOYMENT:
BUSINESS TELEPHONE NUMBER:   BUSINESS TELEPHONE NUMBER:

List all adults who will reside with Applicant(s):
Nearest friend or relative not residing at this residence:   Relationship:
Address:  Telephone Number:

The Applicant certifies that the one box marked is the predominant use of electricity. If energy purchased results in a sales tax liability due to use other than stated, the Applicant assumes responsibility for remitting such tax due directly to the the Director, Missouri Department of Revenue.

I (WE), THE APPLICANT(S) FOR SERVICE, RENT  OWN THE PROPERTY WHERE METER IS LOCATED

If meter is located on rental property, please indicate name of property owner or manager:
Address of property owner or manager:Telephone number:

Sac Osage Electric Cooperative, Inc. is hereby authorized to make any investigation of my personal history and financial and credit record through any investigative or credit agencies or bureau. The provisions of the Fair Credit Reporting Act will be applicable if a credit report on the applicant is obtained and considered.

AUTHORIZATION TO RELEASE CONFIDENTIAL OR PRIVILEDGED INFORMATION CONCERNING ACCOUNT STATUS

     If the applicant for service has checked the box above indicating that said applicant is a renter and has further stated that he is a tenant upon property being serviced by the Cooperative, said applicant expressly authorizes the Cooperative to release and disclose informtaion concerning the status of his membership account with the Cooperative to the poperty owner. The Cooperative represents that the information concerning account stuts will not be disclosed to the property owner unless the member becomes delinquent in the payment of his account or otherwise fails to abide by the terms of the application, Articles of Incorporation, bylaws or policies of the Cooperative as established from time to time by the Board of Directors of the Cooperative. It is the intent of this authorization to permit the Cooperative to notify a property owner of a delinquency so as to give a property owner an opportunity to cure any defect or otherwise make arrangements to avoid a dicontinuance of service, the result of which might be damage to property owned by the property owner.
     By submitting this application, the member/applicant authorizes the release of this infromation with full knowledge and understanding that the confidentiality of this information might be protected by state law, federal law or both.
By submitting this application, the member/applicant states that the infomration provided herein is accurate to the best of his/her knowledge and no attempt has been made to misrepresent the facts. A copy of the completed application will be mailed back to the member/applicant for signature.

Today's Date:

APPLICANT(S) IS(ARE)

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