Name of Service Customer *

First Name

Last Name

Service Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization is being given to:

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship to Service Account Holder

Check one of the following

Parent

Guardian

Other

By signing this agreement, I am authorizing the above individual(s) to have access to my account with Murray Electric System. I also understand that the above stated individual shall be allowed access until I remove them. This shall include the following:

Check each box that you wish to authorize

Service Status

General Information

Change General Information (ex. Phone #)

Disconnect Electric

Connect/Disconnect BB Services

Change BB Services

Signatures *

By checking the box provided below: You are requesting Murray Electric System to furnish electric and/or broadband services to the address listed above; you agree to receive and pay for said services in accordance with the MES Schedule of Rules & Regulations; you certify and agree to a credit check that will be performed on ALL applicants listed above through Online Utility Exchange to partially determine deposit amounts; you understand the deposit you pay today (if applicable) is not a payment, will be held until services are terminated, and applied to the final bill. IF there is a credit balance after the deposit is applied, the credit will be returned to the depositor at the forwarding address on file; you have been advised that the Rules & Regulations of MES are available for you to read, and a copy will be provided upon request at no charge; you acknowledge the schedule of Rules & Regulations shall term, subject to change without notice, and are a part of your contract with MES; you are responsible for any outstanding balance on any old account (s). If these accounts are not paid on the due date, the amount can be transferred to your new account automatically and due with your current account’s balance. Failure to pay this amount will make you eligible for disconnect at the current service address. Should your account become delinquent and past due for a period of 30 days (or more) on your final bill, your account may be sent by Murray Electric System to a third-party collection agency for collection. In addition to the delinquent account balance, the following amounts will be added to the balance due to reflect the charges assessed by the collection agency for the cost of the collection: accounts past due 30-90 days -$12.50, accounts 90 days or more -54% of the total balance. The customer acknowledges and agrees that the delinquent account balance will be increased by the $12.50 and possibly an additional 54% to cover the cost of collection.

Service Customer Check Here

Authorized User Check Here

Date

MM

DD

YYYY