Enrollment Form Today's Date* MM slash DD slash YYYY Agent Name* New Customer - Renewal*Please select oneNew CustomerRenewalNew Customer and RenewalAccount Type*Please select oneCommercialIn Home BusinessResidentialNumber of Accounts*Please select one12345678910 +Customer Name* First Last Title* Business Name* Supplier*Please select onePublic PowerConsolidated CommunicationsTriEagle EnergyUS Gas & ElecChampion EnergyDiscount PowerTown Square EnergyBig Sky GasGreat Eastern EnergySFE EnergyDirect EnergyGlacial EnergyAstral EnergyAgera EnergyDiscount PowerEntrust EnergyPhone Number*Fax NumberEmail Account 1Utility:*Please select oneCT- Connecticut Light & Power dba Eversource (CLP)CT- The United Illuminating Company (UI)DC- Pepco Holdings (PEPCO)DE- Delmarva (DPED)IL- Ameren (AME)IL- Commonwealth Edison (CoMed)MA- National Grid - Mass Electric (MECO)MA- NSTAR - Boston Edison (BECO)MA- NSTAR - Cambridge Electric (CAMB)MA- NSTAR - Commonwealth Electric (COM)MA- Western Massachusetts Electric Company (WMECO)MA- Fitchburg Gas and Electric Light Company d/b/a UnitilMD- Baltimore Gas & Electric (BG&E)MD- Delmarva (DELMD)MD- PEPCO (PEPCOMD)MD- PotomacEdisonMD- Southern Maryland Elec (SMECO)MD- Washington Gas & LightMT- NorthWestern EnergyME- Central Main Power (CMP)ME- Bangor Hydro Electric (Emera BH) (BHE)NH- Public Service of New Hampshire (Eversource) (PSNH)NJ - Public Service Electric and Gas Electric (PSGE)NJ- Atlantic City Electric (ACE)NJ- JCPL - (First Energy) (JCPL)NJ- Rockland Electric (RECO)NY- Central Hudson (CH)NY- Consolidated Edison Inc (CONED)NY- Niagra Mohawk (NIMO) aka National GridNY- NYSEGNY- Orange and Rockland (OR)NY- Rochester Gas & Electric (RGE)OH- AEP Columbus Southern Power Ohio (CSP)OH- AEP Ohio Power (OPC)OH- Dayton Power and Light (DPL)OH- Duke Energy Corporation (DUKEOH)OH- Ohio Edison (OE)OH- Cleveland Electric Illuminating Company (CLEIC)OH- Toledo Edison (TE)PA- Philadelphia Electric Company (PECO)PA- Duquesne Light Company (DUQ)PA- METED - (First Energy) (METED)PA- Pennsylvania Power and Light (PPL)PA- PENELEC - (First Energy) (PENELEC)PA- WPP - Went Penn Power (First Energy) WPPPA- Penn Power (PNPR)PA- UGIPA- PIKEPA- Peoples Natural GasPA- National Fuel of PAPA- Columbia Gas of PAPA- AlleghanyRI- Narragansett (bills will likely say National Grid) (NEC)TX - ERCOTAccount Number (11 digits)* CLP - starts with 51 WMECO- starts with 54 PSNH- starts with 56POD ID Number* UIName Key* 4 CharactersService Number* Account Number* *DUKEOH- Invoice will have 11 Digits, remove the last digit *Central Hudson- drop the last digit to make 10Account Number* CMP- assume there's a missing leading "0" (for a total of 14 numbers)Account Number* (REQUESTING ONLY WITH 8 DIGITS) The first 8 digits are leading 0's, remove those as well as the very last digitElectric Choice ID* POD ID Number* Starts with PE and is 20 characters including PECustomer Number* Starts with 080 Account Number* POD ID Number* *NYSEG- Starts with "N" *RGE - Starts with "R"Service Delivery Number* *CSP- starts with "0004" *OPC- starts with "0014"Suplier Agreement ID* Account Number* Name on bill* Start Date & Year* Term* Rate* Monthly Usage from bill* Service Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the billing address the same?* Yes No Billing address if different ** Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional AccountsMultiple Accounts*NotesRate & TermAccount #Serv. AddressCityStateZipKWH *Please fill out each section*Additional InformationTax Id Number* Customer Status*Please select oneSubmitted for TPVSubmitted for future TPVSend Enrollment FormCustom Price RequestWaiting On Bill(s) TPV CompletedCompleted TPVEnrollment Form SentSigned Enrollment FormWaiting On Bill(s) Signed Enrollment FormNot InterestedDuplicate EnrollmentRejectedResidentialAdditional NotesBill InformationPlease have bills sent to Email: *[email protected] or [email protected] Fax: 888-908-6090 Mail: 51 S Main Ave, STE 312, Clearwater, FL 33765Admin USE ONLY Δ