New Member

First Name as it appears on utility bill (required)

Last Name as it appears on utility bill (required)

Utility Selected

Account Number as it appears on utility bill

Rate Plan Selected (required)

Your Chosen Charity

Phone Number (required)

Licence

Licence State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Your Email (required)

Confirm Email (required)

Address1(Service Address as it appears on utility bill)

Address2

City

State

Zip Code

Signature (required)
[signature* signature-567 class:signature rows:150]

Release: I request and hereby agree and understand that the retail service provider of the rate plan I selected will submit enrollment requests with my Utility to provide the above indicated services. I hereby authorize my local utility to release usage history, meter and credit history information to the provider of the Rate Plan I selected for the duration of this Agreement. Electronic acceptance of a sales agreement is an agreement to initiate service and begin enrollment.

I have received, read and agree to the Terms and Conditions provided to me by Charity+Power.

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