NameThis field is for validation purposes and should be left unchanged.Name(Required) First Last Account NumberMeter NumberDay Phone(Required)Evening PhoneCell PhoneEmail Address Service Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Bill Due Date (mm/dd/yyyy)(Required) Month Day Year Proposed PaymentsThis proposal is subject to review and approval by the Habersham EMC Member Services Department. In no way does the submission of this form guarantee that the proposed extension will prevent disconnection of electric service. Please be sure to fill in all the blanks so that Member Services personnel may contact you. You will be notified if the proposed arrangement is acceptable or not.
