A social security number AND state issued id or passport are required to complete this online application.

IMPORTANT NOTE: ALL APPLICANTS ARE REQUIRED TO PROVIDE A COPY OF THEIR PHOTO ID TO newservicerequest@fairfield.coop. YOUR REQUEST WILL BE PUT ON HOLD UNTIL ID IS PROVIDED.

If you are lacking either, please visit one of our offices to apply in person. Click here to find the office nearest you.

Once submitted, this application will be transmitted to a member service representative for review. You will be contacted by phone to complete the application process and to notify you of any deposits or fees associated with connecting this service.

Applications received on weekends, holidays, or after business hours will be reviewed on the following business day.

A CREDIT CHECK WILL BE RAN IN ORDER TO DETERMINE IF A DEPOSIT IS REQUIRED.

Note: All fields with the asterisk (*) are required.

Today's Date:  
Date Service is Desired:  *  
Type of Request:   *
Member Information:
First Name:		   *
Last Name:   *
Middle Initial:  
Social Security #:--  *
Driver's License #:  *
License State:  
Birth Date:
(mm/dd/yyyy format)		    

Mailing Address:
Street Address/P.O. Box:  *
City:  *
State:  *
Zip Code:   *

Service Address: (Physical 911 Address of Location)
Service Address:  
Comments:  
E-mail:  *
Confirm E-mail:  *
Home Phone:--   *
Cell Phone:--   *
Work Phone:--   
Co Applicant Information:
Name:		 
Social Security #:-- 
Driver's License #:  
License State:  
Birth Date:
(mm/dd/yyyy format)		    
Electronic Signature: I understand that by typing my name, as the listed Spouse, in the field provided that this is electronic signature and that I agree to all terms and conditions herein as coapplicant.
*Required if Spouse		  

Member Portal Access:
We offer a portal for online bill payment and account management.  If you would like access to your account online, please create a password and password hint now for easy access to your account at https://www.fairfield.coop/.   

Please note: Passwords must be a combination of letters and numbers.
Internet Password:  
Confirm Internet Password:  
Password Hint:


Membership Fee:  
Connect Fee:  

Do you own or rent the service location?   *
Would you like to participate in Operation Round Up?
*Your bill will be rounded up to the nearest dollar to help our community		   *
Please select your preferred Billing Method:   *
Please select your preferred Past Due Method:   *
 
The Undersigned (hereinafter called the applicant) hereby applies for service by Fairfield Electric Cooperative, Inc., (hereinafter called the Cooperative) and agrees to purchase all electric service at this location from the Cooperative.  The fee to be leased upon the type of service rendered.  All Cooperative rates and service charges are found in the rules and regulations. By submitting this application, Applicant also agrees to a credit check.

The undersigned (hereinafter called the “Applicant”) hereby applies for membership in and agrees to purchase electric energy from Fairfield Electric Cooperative, Inc. (hereinafter called the “Cooperative”) upon the following conditions.

The applicant will comply with and be bound by the provisions of the charter and bylaws of the Cooperative, and such rules and regulations as may be adopted by the Cooperative.  

The applicant agrees to grant the Cooperative the right to construct, operate, maintain, replace, and relocate upon his land identified above, all electric distribution and/or service line and also to keep clear of shrubbery and dangerous trees.
I understand that checking this box and typing my name in the field provided below is my electronic signature. I also understand that I am required to provide a copy of my ID, as well as the Co-Applicant’s ID (if applicable).
  Member Name:     *