r You will not be able to submit this form before speaking to a customer service representative and attaining an account number. Call 800-889-6832 Option 1 for more information. CLICK TO CLOSE Membership Application Step 1 of 7 14% Account Number * RequiredYou will not be able to submit this form before speaking to a customer service representative and attaining an account number. Call 800-889-6832 Option 1 for more informationLocation NumberMembership Number Applicant InformationApplicant Name * Required First Last Applicant Social Security Number (Last 4 digits only) * RequiredApplicant Date of Birth - must be mm/dd/yyyy format * Required Applicant Driver's License Number and State Spouse Information (if applicable)Spouse Name First Last Spouse Social Security Number (Last 4 digits only) * RequiredSpouse Date of Birth - must be mm/dd/yyyy format Spouse Driver's License Number and State Usage of ElectricityApplicant is to list all adults who will reside with Applicant at the premises described below to be served by the Cooperative. (Applicant represents to the Cooperative that neither Applicant or any adult listed above have received the benefit of electric service from the Cooperative at any service location for which there remain an unpaid charge for electricity.)The Applicant certifies that the one box marked is the predominant use of electricity. If energy purchased results in a sales tax liability due to a use other than marked, the Applicant assumes responsibility for remitting such tax due directly to the Director, Missouri Department of Revenue. Failure to mark box will automatically result in paying tax. * RequiredHouseholdCabinIncome Producing Rental PropertyPrimarily Farm UseCommercialOther Other Other Other Contact InformationMailing Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Physical Address Same as Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Cell PhoneHome PhoneEmail Address * Required Employer InformationEmployer * RequiredEmployer Phone * Required Agree to Terms & ConditionsThe undersigned, hereinafter referred to as “Applicant,” hereby makes application for membership in the Osage Valley Cooperative Association, hereinafter referred to as “Cooperative,” and Applicant andCooperative also enter into the following agreement for electric service: 1. This form must be fully, truthfully, and accurately completed by Applicant to be considered for acceptance by the Cooperative’s Board of Directors. Any service extended Applicant prior to acceptance or rejection of this Application for Membership shall in no way operate as a waiver or estoppel against the Cooperative. 2. Applicant will pay to Cooperative the sum of $20.00, which upon acceptance will constitute Applicant’s membership fee. As a member of the Cooperative, Applicant will not assume personal liability for anyCooperative debts of liabilities. Applicant also agrees that $3.36 paid for electric service each year is for annual subscription to the “Rural Missouri” magazine. 3. The acceptance of this application by the Cooperative shall constitute a binding Agreement between the Applicant and the Cooperative, and the Agreement shall continue in force until disconnection of service, beginning from the date service is made available to the Applicant. 4. When electric energy becomes available, Applicant agrees to purchase from Cooperative all central station electric power and energy used on the premises described below. All electric power and energy purchased shall be paid at rates and terms as set out in the Cooperative’s rate schedule and policies, as from time to time are adopted by the Cooperative Board of Directors. 5. Applicant will furnish without cost right-of-way required by the Cooperative to furnish electric service to Applicant. In addition, Applicant will furnish without cost right-of-way over lands of the Applicants in order that the Cooperative may construct, operate and maintain distribution lines to render electrical service to other Applicants or members of the Cooperative who cannot be conveniently and economically provided electric service in any other manner. Said rights-of-way shall provide the Cooperative rights of ingress and access, rights of maintaining and operating the Cooperative’s facilities, and all other duties necessary to operate and maintain the Cooperative’s system. 6. As a member of the Cooperative, Applicant agrees to comply with and be bound by, as though fully set out herein, all provisions of the Cooperative's Articles of Incorporation, Bylaws and service policies as they presently exist, or as they may from time to time be adopted, rescinded, or amended by the Cooperative. 7. Electric service is to be delivered and received at a mutually agreed point on Applicant's premises. The Cooperative's meter shall constitute the point of delivery, and the Cooperative shall own, maintain or replace when necessary, and be responsible for, all poles, wires, and appurtenances furnished to and including the delivery point. Applicant shall own, maintain or replace when necessary, and be responsible for, all poles, wires, and appurtenances beyond the delivery point. Applicant further agrees to protect all Cooperative property, including electric meters, located on the premises ofApplicant, and to be responsible and hold the Cooperative harmless from any unauthorized meter tampering or diversions of electricity occurring on any premises of Applicant served by the Cooperative. 8. From time to time the Cooperative may refund monies to you in the form of retirement of capital credits, refunds of deposits and overpayments or the like. These payments will be sent to the address the Cooperative has in its records for you. Please be sure that even if you are no longer a member of the Cooperative that the Cooperative has a valid address for you. Any such check which are not returned or are lost and not presented for payment to the Cooperative’s bank will be handled according to Article 6, Section 5 of the Cooperative’s bylaws; which provide: these monies will be assigned and given to the cooperative. 9. As a member of the Cooperative, Applicant agrees to receive communications via electronically generated notifications, from the cooperative. 10. Applicant’s membership is not assignable or transferable. This Electric Service Agreement shall not be transferable or assignable by either Applicant or Cooperative without the written consent of the other. This Agreement shall be binding upon the heirs, successors, executors, administrators and assigns of Applicant and Cooperative.Name of Person Completing This Form * Required First Last Effective Date to Begin Service* - must be mm/dd/yyyy format Signature * RequiredI understand that this digital signature constitutes a legal signature confirming that I acknowledge and agree to the terms of this application. Submit This iframe contains the logic required to handle Ajax powered Gravity Forms.