APPLICATIONFORMEMBERSHIP/ADDITIONALCONNECTION
ANDAGREEMENTFORELECTRICSERVICE
Theundersigned(hereinaftercalledthe“Applicant”)herebyappliesfor(membership)(additionalconnection)in
andagreestopurchaseelectricenergyfromShelbyElectricCooperative(hereinaftercalledthe“Cooperative”)
uponthefollowingtermsandconditions:
1. TheApplicant,insomecases,mayberequiredtoprovideasecuritydepositanddeterminedbythe
Cooperative.
2. TheApplicantagrees,pursuanttothisagreementforelectricalservice,topaymonthlyforallelectricalenergy
suppliedbytheCooperativeatratestobeestablishedfromtimetotimebytheBoardofDirectorsofthe
Cooperative;provided,however,thattheCooperativemaylimittheamountofelectricalenergyfurnishedfor
industrialuses.$4.50oftheamountaccruingtomeeachyearisforayear’ssubscriptiontoShelbyNews.Inthe
eventthattheamountaccruingtomeisinsufficienttocoverthepriceofthesubscription,Iauthorizetheboardof
directorstopayforitoutofamountspaidbymeforelectricservice.
3. TheApplicantwillcausehispremisestobewiredinaccordancewiththewiringspecificationsapprovedbythe
Cooperative.
4. TheApplicantagrees,pursuanttothismembershipcontract,tocomplywithandbeboundbytheprovisionsof
thecharter,bylaws,policies,rules,andregulationsoftheCooperativeastheynowexistormayfromtimetotime
beadoptedoramendedbytheCooperative,andfurtheragreestoretroactiveapplicationofanyamendments.As
partofthismembershiptheapplicantagrees,whenelectricenergybecomesavailable,topurchasefromthe
Cooperativeallelectricenergypurchasedforuseonthepremisescoveredbythisapplication.
5. TheApplicantagreestofurnishtotheCooperativeatnocostaright-of-wayeasementtoconstruct,operate,
repair,replace,improve,andmaintainelectriclinesandservices,whichprovideelectricservicetothemembersof
theCooperative.Theeasementshallbedraftedinaccordanceandcomplywiththecooperativesoperation
policiesconcerningeasementsrequiredforelectricservice.
6. TheApplicantbybecomingamemberassumesnopersonalliabilityorresponsibilityforanydebtsorliabilities
oftheCooperative,anditisexpresslyunderstoodthatunderthelaw,hisprivatepropertyisexemptfrom
executionforanysuchdebtsorliabilities.
7. AcceptanceofthisapplicationbytheCooperativeshallestablishamembershipandanagreementforelectric
servicebetweentheApplicantandtheCooperative.TheagreementforElectricServiceshallcontinueinforce
fromthedayservicebytheCooperativetotheapplicantbeginsuntilcanceledbyatleast30dayswrittennotice
givenbyeitherpartytotheother.Themembershipshallcontinueinforceuntileitherpartyterminatesthe
membershipofApplicantinaccordancewiththebylawsandpoliciesoftheCooperative.Removalor
disconnectionofthemeteratanytime,whethertodiscontinueserviceforanunpaidaccountorforanyother
reason,bytheCooperativeshallnotconstituteabreachofeithercontract.
8. Falsificationofanyofthefollowinginformationmayresultindisconnectionofservicewithoutnotification.
9. Ifinitialedhere:
:Applicationshallprovideaconstructiondepositof$
beforecommencementofconstructionofalineorelectricalfacility;andthisdepositshallbereturnedasacredit
oneachmonthlybilluntilthedepositisexhaustedor
monthshaveelapsed.Norefund
shallbemadeofanyportionofthedepositremainingupontheterminationoftheelectricservicepriorto
exhaustionofthedepositorearlyterminationasmaybeallowedbytheCooperativeandallsuchfundsremainthe
propertyoftheCooperative.
Shelby Electric Cooperative | PO Box 560 | 1355 HWY 128 | Shelbyville, IL 62565 | 800-677-2612
Page 1 of 2
APPLICATIONFORMEMBERSHIP/ADDITIONALCONNECTION
ANDAGREEMENTFORELECTRICSERVICE
MEMBERINFORMATIONSECTION:
Date
Witness
Member–PrintName/BusinessName
JointMemberName–Print
MemberSignature
JointMemberSignature
MemberSocialSecurityNumber/FEINNumber
JointMemberSocialSecurityNumber
MemberDriver’sLicense
JointMemberDriver’sLicense
MemberDateofBirth
JointMemberDateofBirth
Spouse–PrintName
SpouseSignature
MailingAddressforBilling
HomePhoneNumber
City
CellPhoneNumber
ServiceAddressofMeter
EmailAddress
City
State
Zip
State
Zip
----------------------------------------------OFFICEUSEONLY-------------------------------------------------
AccountNumber
MapLocation
CustomerNumber
Cash$
ORIGINAL
Check
ADDITIONAL
Prepay
Add
FORRECORDSONLY
Shelby Electric Cooperative | PO Box 560 | 1355 HWY 128 | Shelbyville, IL 62565 | 800-677-2612
Page 2 of 2