Application for Membership and Service Agreement
Please complete the below application to apply for new service.  A membership fee of $ 20 is required to become a member of and receive service from Coahoma Electric Power Association.  Each service may require a security deposit in addition to the membership fee.  The amount of the deposit required in each case will be determined by the association and kept within the guidelines set forth by the Mississippi Public Service Commission.  If you have any questions regarding service, please feel free to contact our office during normal business hours, Monday -Friday 7:30 am - 4:30 pm, (662) 624-8321.

Fields with the asterisk (*) are required.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Applicant's First Name:   *
Applicant's Last Name:   *
Applicant's Middle Initial:  
S.S. #:--  *
Driver's License #:  
License State:  
Birth Date:    
Employer:  
Employer Address:  
City:  
State:  
Zip Code:  

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

Service Address:
Please enter the street address where service is required: 
Service Address:   *
Comments:  
E-mail:  *
Confirm E-mail:  *
Home Phone No.--   *
Cell Phone:--  
Work Phone No.--   
Name of Spouse: 
Spouse's S.S. #:-- 
Spouse's Driver's License #:  
Spouse's License State:  
Spouse's Birth Date:    
Spouse's Employer:  
Joint Membership:
(please indicate yes or no)		  *

Online Portal:
We offer an online portal that can be used for viewing and paying bills, as well as managing other account options.  If you would like to create a portal login, please specify a password below.  Your password must be a combination of numeric and alpha characters. 
 
Internet Password:  
Confirm Internet Password:  
Password Hint:

Existing/Previous Service:
Have you ever had service with us before?
    
Account Number:
Membership Fee & Security Deposit
A membership fee of $ 20 is required to become a member of and receive service from Coahoma Electric Power Association.  All applicants for membership must be approved by the Board of Directors.  The membership fee is refundable to the member upon termination of service and payment of all final charges.  Each service may require a security deposit in addition to the membership fee.  The amount of the deposit required in each case will be determined by the association and kept within the guidelines set forth by the Mississippi Public Service Commission.  Deposits are refundable, with interest, upon termination of service and the payment of all final charges.  Once your account is created in our system, you will receive an email with the total amount due on your new account, including deposit amount, when applicable.

Membership Fee:  

Do you rent or own at the service location?   *
Please select your preferred billing method:   *
 
By checking this box and submitting this service request, I have read, understand and agree to the service agreement and bylaws of Coahoma EPA. 
 
I understand that checking this box and typing my name in the field provided below is my electronic signature.
 
  Applicant Name:     *