Customer Name:
Last       First       Middle

Service Address:

Date requested for connection  (mm/dd/yyyy)                              Yard Light   yes      no

Mailing Address
                      Lot/Apt # 

Social Security Number                               Date of Birth  (mm/dd/yyyy) 

Driver's License Number                                                             State 

Employed by: 

Home Phone Number                              Business Phone Number 

Cell Phone Number                                             Contact Number 

Email Address 

Spouse's Name:
Last      First      Maiden 

Spouse's Social Security Number                 Date of Birth  (mm/dd/yyyy) 

Spouse Employed by: 

Own Home  yes      no                                 Rents From 

Nearest Relative                    Relationship 

Address 

Phone 

List all members of Household:

             Name                                     Social Security Number                Date of Birth (mm/dd/yyyy)

Do you have other accounts with Paducah Power System?   yes        no

If yes, would you like for us to disconnect your current service?    yes      no

I request Paducah Power System (hereinafter referred to as system) to connect electric service to the address shown hereon. I agree to receive and pay for connection service in accordance with the systems "standard rules, rates, and regulations". I agree to permit authorized agents of the system free access to the premises for the purpose of inspecting, reading, repairing or removing property of the system. The system shall have the right, but shall not be obligated, to inspect any installation before service is turned on, or at any time, and reserves the right to reject any wiring that is not in accordance with the systems standards. Failure to inspect or reject shall not render the system liable or responsible for any loss or damage resulting from defects or violation from the systems rules and I certify the above information to be correct to the best of my knowledge.