Membership Application Current Page 1- Initial Info. Page 2- Applicant Info. Page 3- Address Page 4 -Account and Billing Page 5- Co-Applicant Info. Page 6- Additional Account Info. Page 7- Terms of Service Complete Initial Information Before Completing this Membership Application, make sure you have the following information nearby: -Photo ID -Electric Meter Number if the request is for an existing structure -Completed Rental Agreement (can be found here) if you are renting. -Service/911 Address -Mailing Address if different Date Service is desired: If you need same day service request, please call our office. Online service requests may take up to 72 hours to initiate. Type of Request: Please select one type of service request option. - Select -Residential Non-Residential Have you ever had service with us before? - Select -YesNo Page 2- Applicant Information Electric Disconnect Service Request Form Stop Service- Electric Disconnect Service Request Form Date of Disconnect (Business days only. Can not be weekends or holidays) Member First Name:? Member Last Name:? Phone Number: E-mail Address (Please enter the applicant email address) Please select the the water service option that applies to you: - Select -Cullman County WaterOther Would you like your Cullman County Water Account disconnected? - Select -yesno Please contact your water provider directly to disconnect water services Please contact your water provider directly to disconnect water services Account to Disconnect Account Number: Service Address/E-911 Address Unit, Lot, Apt. Number, etc. City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Do you plan to move or demolish the current structure at this location? - Select -yesno Forwarding Address: Street Address Unit, Lot, Apt. Number, etc. City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code I understand that checking this box and typing my name in the field provided below is my electronic signature.* Applicant Signature Reset Sign above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit