Sam Houston Electric Cooperative

ELECTRIC SERVICE REQUEST FORM

GENERAL SERVICE REQUEST FORM

Please note: In addition to filling out this online form for electric service, a signed Application for Membership must be submitted. To expedite your request for service, please print the Application for Membership,fill it out, sign it and return it by mail, fax, or in person at any branch office. A Member Services Representative will contact you shortly to assist you in completing your order.

1. How may we contact you?

First Name*	Last Name*
Preferred Contact Phone Number *
Alternate Contact Phone Number
Email
Street Address
City
State	Zip

2. Do you currently have service with Sam Houston Electric?

Yes No

3. Has electric service been at this location before?

Yes No

If Yes:

Meter #

Who was the last person w/ electric service as this location?

First Name

Last Name

Description of Location (example: Residential, Commercial, Landmarks, House Color, Mobile Home, etc.)

What community is the property located in? (or near)

If No:

What is the legal description of the property?

Lot

Block

Section

Subdivision

Street Address

What community is the property located in? (or near)

County

What is the name of your nearest neighbor?

First Name

Last Name

What is the phone number of your nearest neighbor?

What is the distance to the closest existing pole?

Is the closest existing pole on the same side of the street?
Yes No

Permit #

Will the permanent service be underground or overhead?
Undgerground Overhead

Is the meter loop ready?
Yes No

4. Would you like a Security Light?

Yes No

5. Would you like Surge Protection?

Yes No

* Required fields

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