Have tenant complete application prior to move in
Form 6174 Rev. 3/12
[pic]
Minnesota Power
Application for Residential Electric Service
Please send completed form to 30 W Superior St. Duluth, MN 55802, fax to 218-355-2770, or apply online at .
| |
|Account # |
| |
|Date to Start Service |
| |
|Own Rent |
| |
|Landlord Name |
| |
|Landlord Phone # |
Last Name First Middle
Service Address
City State Zip
Mailing Address
City State Zip
Primary Phone # Cell Phone #
Employer Employer Phone #
SSN Driver’s License # State Other ID
Previous Address City/State/Zip
Have you ever been a customer of Minnesota Power? Yes No
If yes, prior service address
Contact Person not living with applicant Relationship
Address City/State/Zip Phone #
Primary Signature Email Address
Spouse/Roommate: All adults receiving electric service at this premise are required to be listed on the account and will be held equally responsible for charges incurred.
Last Name First Middle Social Security #
Driver’s License # State Cell Phone #
Employer Employer Phone #
Previous Address City/State/Zip
Contact Person not living with applicant Relationship
Address City/State/Zip Phone #
Secondary Signature Email Address
Please notify Minnesota Power when you move. You are responsible for all electric bills through the date we are notified.
( ( ( ( ( ( (
Adults/Roommates complete reverse side
Adults/Roommates:
Last Name First Middle Social Security #
Driver’s License # State Cell Phone #
Employer Employer Phone #
Previous Address City/State/Zip
Contact Person not living with applicant Relationship
Address City/State/Zip Phone #
Roommate Signature Email Address
----------------------------------------------------------------------------------------------------------------------------------------------------------------
Last Name First Middle Social Security #
Driver’s License # State Cell Phone #
Employer Employer Phone #
Previous Address City/State/Zip
Contact Person not living with applicant Relationship
Address City/State/Zip Phone #
Roommate Signature Email Address
----------------------------------------------------------------------------------------------------------------------------------------------------------------
Last Name First Middle Social Security #
Driver’s License # State Cell Phone #
Employer Employer Phone #
Previous Address City/State/Zip
Contact Person not living with applicant Relationship
Address City/State/Zip Phone #
Roommate Signature Email Address
----------------------------------------------------------------------------------------------------------------------------------------------------------------
Thank you for completing this application! Any outstanding electric service bills from Minnesota Power will be transferred to your new account. If you have further questions, please contact Minnesota Power at
1-800-228-4966 or via email at customerservice@.
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