Date: *

MM

DD

YYYY

Name: *

First Name

Last Name

Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone: *

(###)

###

####

Sources of Income: *

Check all that apply.

Employment

AFDC / GA / GA Med. Care

Medical Assistance

Disability / Social Security / Pension

SSI / Food Stamps / XSA / Children's Health Plan

I do not pay for my own medical expenses.

Please check if the following exists in your home:

Check all that apply.

Medical Emergency

Disabled Person in Residence

Elderly Person

Acknowledgement Agreement: *

By checking this box I authorize any gas or electric utility that serves us to exchange billing information. I acknowledge that I have received, read and understand the Notice of Residential Member Rights found on BENCO Electric Cooperative's website. I attest that the above information is true and correct.

Yes