New Membership Application

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Effective Date: (if rental) Landlord First Name:
Landlord Last Name:

First Name:
Last Name:
First name of additional occupant:
Last name of additional occupant:
Mailing address:
City:
State:
Zip Code:
Home Phone (including area code, no spaces):
Alternate Phone (including area code, no spaces):
Email Address:*
SS# or Federal ID#:
SS# or Federal ID# of other occupant:
Have you been on our lines before?
If you are a current member, would you like this account billed with your present account?
Which method would you like us to use to confirm your membership application?:

Current Tenant Name:
Location # or Account # (located on bill):
Forwarding address of person moving out:
City:
State:
Zip Code:
Phone (including area code, no spaces):
Will the person moving out remain on our lines?

BEC meter number (located on the face of meter):
Final reading of main meter (must be 5 digits):
Final reading of off-peak meter (if applicable):
Name of person reading meter(s):
Date read:

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Beltrami Electric Cooperative, 4111 Technology Dr NW, PO Box 488, Bemidji, MN 56619-0488
Phone: 218-444-2540 or 1-800-955-6083 Fax: 218-444-3676 email: info@beltramielectric.com
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