SQUIGS COMPUTERS ENERGY FORM
Customers Full Name:
*
Customer Type
*
Residential
Business
Rate Group
*
Please Select
Fixed
Variable
Green
Are you currently an Ambit customer
*
Yes
No
If Yes Account Number
PPL Account Number
Gas Account Number
Addresss
*
City
*
State
*
Zip Code
*
Home Phone
*
Cell Phone
*
Best contact number
*
Home
Cell
E-mail Address
*
Submit
Should be Empty: