Thank you for being a member of BENCO Electric Cooperative! Please complete this application if you are moving into a home in the BENCO service territory.

Date Service Begins *
Date Service Begins
Date of closing (if purchasing the residence) or beginning of lease (if renting the residence).
Name *
Please include First Name and Middle Initial.
Service Address *
Service Address
Mailing Address *
Mailing Address
Phone Number *
Phone Number
Date of Birth *
Date of Birth
Is there a Joint Applicant for this account? *
If yes, Joint Applicant Name:
If yes, Joint Applicant Name:
I am *
Have you previously been a BENCO member? *
Must be an adult who does not live at the residence.
Requested by: *
Requested by:
Person submitting application.