Application for New Service

Date:


Customer First Name:


Customer Last Name:


E-Mail Address:


Phone Number:


Present Mailing Address:

City Name:

State:

Zipcode:

---

Address of Property to be Served:

911 Address:

City Name:

State:

Zipcode:

Subdivision and Lot Number:

County:

Tax Map:

Parcel:

---

Service Size Requested:

200 Amp		320 Amp		400 Amp (Bolt-In Meter)	Other
Single Phase		Three Phase		Voltage

Type of Heating:

Heat Pump

Electric Baseboard

Gas

Other

Type of Water Heater:

Electric

Gas

Central Air:

Yes

No

General Contractor:			Phone:
Electrical Contractor:			Phone:

Construction Start Date:  

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Choptank Electric Cooperative, Inc., 10384 River Road, Denton, Maryland 21629 Toll Free: 877-892-0001