PCEC Membership Application
Application to start service with Platte-Clay Electric Cooperative.
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 Director, Missouri Department of Revenue.
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Household
Agricultural
Commercial
Other
Start Service Date:
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/
Month
/
Day
Year
Date
Do you own or rent the property?
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Own
Rent
If renting, please list property owner's name:
*
Applicant Information
The name(s) listed on your account should be exactly as it appears on your Social Security Card (or equivalent documenttation).
Name
*
First Name
Middle Name
Last Name
Physical Address of Service
*
Street
Street Address Line 2
City, State, ZIP
State / Province
Postal / Zip Code
County
*
Please Select
Buchanan
Caldwell
Clay
Clinton
DeKalb
Platte
Ray
Mailing Address (if different from physical address of service)
Street
Street Address Line 2
City, State, ZIP
State / Province
Postal / Zip Code
Primary Phone:
*
Additional Phone:
Email Address:
*
By entering your email address you agree to receive emails from Platte-Clay Electric Cooperative.
Social Security Number or Federal Tax ID:
*
This field is used only for credit verification purposes to determine required deposits. SSN data is encrypted and not stored on PCEC's website.
Date of Birth:
*
/
Month
/
Day
Year
Date
Applicant Signature:
*
Date:
*
/
Month
/
Day
Year
Would you like to add a spouse or co-applicant to the account?
*
Yes
No
Spouse or Co-Applicant
Name
First Name
Middle Name
Last Name
Primary Phone Number:
*
Additional Phone Number:
Email Address:
example@example.com
Social Security Number or Federal Tax ID:
*
This field is used only for credit verification purposes to determine required deposits. SSN data is encrypted and not stored on PCEC's website.
Date of Birth:
/
Month
/
Day
Year
Co-Applicant Signature:
*
Date:
*
/
Month
/
Day
Year
Date
Applicant Initials
*
I have read and understand the above agreement.
Co-Applicant Initials
*
I have read and understand the above agreement.
Notes for Member Service Representative
Please verify that you are human
*
Submit
Should be Empty: