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)

Billing Address – Street

Billing Address – City

Billing Address – State

Billing Address – Zip

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)

Agree?(required)

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.