Existing Home Service Application

Primary applicant
Name

First NameMiddle NameLast Name
Driver's license number
Social security number
Birthdate

MonthDayYear
Date
Primary phone number
Format: 000-000-0000.
Secondary phone number
Please enter a valid phone number.Format: (000) 000-0000.
Primary email address
Previous address

Street Address

Street Address Line 2

CityState

Zip Code
Have you had an account with us in the past?
Co-applicant
Name

First NameMiddle NameLast Name
Driver's license number
Social security number
In order to be listed on the bill, a social security number is required.
Birthdate

MonthDayYear
Date
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Previous address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you had an account with us in the past?
Where are you moving to?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you rent or own?
Lease start/closing date

MonthDayYear
Date
If you rent the property, provide the name of the landlord/owner

First NameLast Name
If the electric service is currently disconnected, you authorize us to reconnect the services on the date of Lease Start/Closing Date entered above.
Is there a fence?
How many dogs are at the home?
I want my bills sent to the above address
Billing address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please verify that you are human
By providing your phone number(s), including any mobile number, you authorize Connexus Energy and its agents to contact you regarding your account using any means, including automatic telephone dialing systems, prerecorded voice messages, text messages, or other forms of communication. You understand that message and data rates may apply. Your consent is not a condition of receiving service. If your number changes, you agree to promptly notify Connexus Energy.
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