Company name
*
Company representative
*
First Name
Last Name
Company representative's title
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact phone number
*
Format: 000-000-0000.
Contact email address
*
Billing address (prefer accounts payable department
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Accounts payable or responsible bill payer email address
*
example@example.com
Are you currently on master summary billing?
*
Yes
No
If yes, please provide master summary billing account number
Accounts
Rows
Original Account Number
(ex: 123456-123456)
Service Address
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
By signing below, you are enrolling in Connexus Energy’s Master Summary Billing Program and understand the above program guidelines. Enrollment is not complete until the completed form is returned to Connexus.
*
Please verify that you are human
*
SUBMIT
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