We are pleased that you have chosen the service area of Chariton Valley Electric Cooperative for your new home or business. Our goal is to make the process of obtaining your new electric service as easy as 1-2-3. Please complete the form below to request new service. 

Chariton Valley Electric Cooperative requires information and signature(s) for the primary applicant, spouse/co‐applicant and any other adults residing at the premise. The name(s) listed on your account should be exactly as it appears on your Social Security Card (or equivalent documentation.) If you have any questions regarding service, contact our office at 641-932-7126 or 800-475-1702.

(*) indicates required field

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Primary Applicant Information:
First Name:		   *
Last Name:   *
Middle Initial:  
Social Security Number:--  *
Driver License #:  *
Date of Birth:  *  
Employer:  
Racial/Ethnic Group:
As a participant in the federal programs, through the Rural Utility Services, Chariton Valley Electric Cooperative, Inc. is required to identify and document as accurately as possible the racial/ethnic data on the eligible population on our service area. We would appreciate your checking of the appropriate group listed below. Please note, your response is optional. The information you provide will be used only for Federal Government Reporting purposes		  

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

Physical Address of Service:
Service Address:  
City, State, Zip:   *
E-mail:  *
Confirm E-mail:  *
Primary Phone:--   *
Cell Phone:--   *
Employer Phone:--   
Spouse/Co Applicant:*Name, SSN, DL and DOB are required if Spouse/Co Applicant. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
Name:		 
Social Security Number:-- 
Driver's License #:  
Date of Birth:    
Employer:  
Employer Phone:  
Email:  
Electronic Signature: I understand that typing my name in the field provided is my electronic signature. *Required if Spouse or Co Applicant  

Online Account Access:
We offer a portal and mobile app for ebill, online bill payment and account management. If you would like to access your account online, please create a password and password hint below. For security purposes, a minimum password length of 10 characters and a combination of uppercase letters, lowercase letters, numbers, and symbols (!@#$%^&*) is required.
Internet Password:  
Confirm Internet Password:  
Password Hint:

Existing/Previous Service:
Have you ever had service with us before?    
Account Number:
Fee and Deposit Information:
Each applicant is required to pay a Deposit or provide a Letter of Credit (with active service within the past 12 months) from your former electric utility and pay the Connect fee and/or Transfer fees.


Any Other Adults Residing at Premises:
Name (1):		  
Phone Number (1):  
Name (2):  
Phone Number (2):  
If Renting:
Property Owners Name:		  
Property Owners Phone Number:  
Do you Rent or Own the property?   *
Would you like to participate in Operation RoundUp®?
Operation Round Up® is a voluntary program in which CVEC members can round their electric bill to the nearest whole dollar amount with the extra change going into a separate Operation Round Up® fund. For example, if your bill is $87.56, you will actually be billed an even $88.00 and the extra $0.44 goes toward helping various goodwill causes in your community. On average, a member will only contribute about $6.00 per year, with the maximum donation amount for the year being $11.88. Please note funds from this program do NOT pay member electric bills.		  
Preferred Billing Method:   *
 
IN CONSIDERATION OF THE MUTUAL PROMISES SET FORTH IN THE AGREEMENT, COOPERATIVE AND MEMBER HEREBY AGREES AS FOLLOWS:
I understand that checking this box and typing my name in the field provided below is my electronic signature.
  Applicant Name:     *