New Service Application

Please complete this form to apply for NEW service only. If you are currently a Flint Energies Member and wish to transfer your current service click here. If you wish to disconnect your Flint service AND are not transferring service to another Flint location, click here.

Note: All fields with the asterisk (*) are required. Incomplete applications will not be processed. Information on this application will be used for the purpose of a credit check through TransUnion. Notice: Flint Energies will only run one credit check per service location.  Depending upon the results of your credit check, you may be required to pay a deposit in full, prior to electric service being connected.

Application Submitted Date:  
Date Service is Desired:  *  
Type of Request:   *
Applicant First Name:   *
Applicant Last Name:   *
Applicant Middle Initial:  
Applicant SSN:--  *
Driver's License #:  *
License State:   *
Date of Birth:  *  
Employer:   *
Employer Address:  *
If Rent, Name of Landlord:  
Landlord Address:  
Would like to receive GA magazine via paper or paperless?  *

Billing Address
Please enter the address where bills should be sent:

Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address
Please enter the street address where service is required:
Service Address:  
Service Type (Construction Required or Existing Service):   *
Comments:  
E-mail:  *
Confirm E-mail:  *
Home Phone:--   *
Cell Phone:--  
Work Phone:--   
Joint Applicant Name: 
Joint Applicant SSN:-- 
Co Applicant Driver's License:  
Co Applicant License State:  
Co Applicant Birth Date:    
Co Applicant Employer:  
Joint Applicant Employer:  
Employer Address:  

*Cooperative will not use member provided contact information for marketing solicitations.

Online Access
As one of our services, we provide an online application for viewing and paying bills.  If you'd like to use this service, you can specifiy an Internet Password and Password Hint at this time.  Please note that the Internet Password must be at least 6 characters in length. 

Internet Password:  
Confirm Internet Password:  
Password Hint:

Existing Service
Have you ever had service with us before?    
Account Number:

Fees
Please Note: Additional services in the same name will not have to pay an additional membership fee. For Pay-Your-Way accounts, a minimum of $50.00 for daily usage is required for initial service.


Membership Fee:  
Setup Fee:  

Name of Nearest Relative Not Living in Household:  *
Relationship to Applicant:  *
Relative Phone Number:  *
Relative Address:  *
By placing "Yes" in the field area provided, I agree to the Service Rules & Regulations and ByLaws of Flint Energies.  *
Would you like to participate in Operation Round Up ?   *
Please select preferred Billing Method:   *
 
I have read and agree to the Service Rules & Regulations , ByLaws, and Pay-Your-Way Terms of Service (if applicable) of Flint Energies. By submitting this application request, I also agree that a credit check may be submitted, if necessary, to determine if a security deposit is required.

Flint requires all information be submitted either in person or notarized copies by mail.  If you choose to submit any information in advance via fax or online, please be advised that the electronic transmission of personal identifying information (driver’s license number, Social Security number, or other identifying information) may be subject to inadvertent disclosure to third parties due to the nature of the technology.  Any delivery of personal identifying information is at your own risk and no guarantee or warranty of privacy, express or implied, is given by Flint Electric Membership Corporation, dba Flint Energies (“Flint”).  Flint will use commercially reasonable measures to protect information received or sent by Flint at your request.  Flint does not use encrypted data to communicate with its customers and members.  
By signing below, you give Flint Energies express consent to send SMS text alerts to inform you of account activity including account balance and usage information. If your mobile number changes, it is important that you contact Flint Energies to update the information. This will minimize interruption in your SMS text alerts service. By signing below, you give Flint Energies express consent to send the Cooperative Service Rules and Regulations via email at the email address provided above. I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *