DOMINION DISCOUNT APPLICATION

Dominion Discount Application

Fill out form carefully for registration.
Is Your Current Electricity Provider Dominion? YES / NO

If YES, you can continue to fill out this form! If your current electricity provider is not dominion, you are not eligible.
Do you have an online account for Dominion? YES / NO*

If NO, you will need to create one.
Customer name

First NameMiddle NameLast Name
Address

Street Address

Apt/Ste/Flr/Trl/Num/Ect

CityState / Province

Postal / Zip Code
E-mail
Must be a valid E-mail address Example: yourname1@gmail.com
Phone Number
must be a valid phone number and must have phone on hand when applyingFormat: (000) 000-0000.
Benefit you receive
Upload a picture of the front of your benefit card

Cancelof
Upload a CLEAR picture of your light bill.

Cancelof
Additional Comments/Questions
Who referred you?
Type a question
Should be Empty:

Dominion Discount Application