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

Date Service Begins *
Date Service Begins
Service Address *
Service Address
Name *
Please include First Name and Middle Initial
Mailing Address *
Mailing Address
Phone Number *
Phone Number
Date of Birth *
Date of Birth
Is there a Joint Application for this account? *
Name 1
Name 1
If yes, Joint Applicant Name
Requested by:
Requested by: