Residential Rates – Sign Up Form First Name(required) Last Name(required) Service Address – Street(required) Service Address – City(required) Service Address – State(required) Service Address – Zip(required) Service Address Same As Billing Address? If Yes, Do Not Complete Billing Address(required) Yes No Billing Address – Street(required) Billing Address – City(required) Billing Address – State(required) Billing Address – Zip(required) Phone Number (000) 000-0000(required) Email(required) Social Security Number 000-00-0000(required) Date of Birth MM-DD-YYYY(required) Current Contract Termination Date(required) Current Electricity Provider(required) Minimum or Maximum Contract Term Length, If Any Switching Retailer?(required) Yes No Agree?(required) Yes No I Agree to establish new electricity service with the electricity retailer recommended by American Enerpower or change my current electricity retailer to the recommended electricity retailer. I authorize American Enerpower to act as my agent to perform the tasks necessary to switch, establish or change my electricity service and retailer. Submit