Application For Residential Broadband Service

Instructions: Be sure to complete, sign and date this application as well as read, agree, sign and date the “Acceptable Use Agreement” document and the “Broadband General Terms & Conditions” agreement

Do you have Electric Service with BEC Power? *

Yes

BEC Account #

** Application must be filled out by an account holder

if you have an active BEC Power account**

Applicant's Full Name *

For Verfication of Account DOB: * +

Social Security # *

Driver License or ID# *

Valid Driver's License Upload *

Service Address (Address, City, State, Zip) *

Mailing Address (If different from Service Address)

Home Phone #

Cell Phone #

Work Phone #

Email Address *

Did someone refer you to us? *

Referral Name: *

Referral Address: *