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Name and/or Address Change Form

Name and/or Address Change Form

New Member Name, Mailing Address and Contact Information

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Country

If name has changed:

These changes are applicable to electric service currently and/or previously rendered at the following service location(s):

Address
Address
City
State/Province
Zip/Postal
Address
Address
City
State/Province
Zip/Postal
Address
Address
City
State/Province
Zip/Postal

I CERTIFY THAT:

There has been no change in account responsibility or in the ownership of the capital credits or of any membership fee or meter deposit credits currently being held by Jackson County REMC. I will indemnify, defend and hold Jackson County REMC harmless against any claims that may arise related to these instructions. I understand that a copy of this document will be released to any party making a contrary claim.
I CERTIFY THAT:
Member Printed Full Name (Or Legal Representative)
Member Printed Full Name (Or Legal Representative)
First
Last

Maximum file size: 33.55MB