Electric Service Application

BIA-DWP-PWR-101
Rev. 01/12/2022

UNITED STATES DEPARTMENT OF THE INTERIOR
BUREAU OF INDIAN AFFAIRS

OMB Control Number: 1076-0021
Expiration Date: XX/XX/XXXX

ELECTRIC SERVICE APPLICATION
COLORADO RIVER AGENCY

SAN CARLOS IRRIGATION PROJECT
P.O. BOX 250
COOLIDGE, ARIZONA 85128
(800) 648-8659 [email protected]

12000 1ST AVE
PARKER, ARIZONA 85344
(928) 669-7173 [email protected]

Check here to apply for service with SCIP

Check here to apply for service with CRA
CRIT Reservation Only

TYPE OF REQUEST
New Service

(select all that apply)

New Construction

Upgrade

Lighting

Relocation

Update Account Info

Requested In-Service Date

Other

APPLICANT Owner

Renter

Contractor

Previous Customer?

Driver License No.

SSN/TIN

Yes

No

Yes

No

State

Name
Mailing Address
City

State

Zip

Email

Phone

Alt. Phone

Paperless Billing

Yes

CO-APPLICANT

No
Previous Customer?

Driver License No.

SSN/TIN

State

Name
Mailing Address
City

State

Zip

Email

Phone

Alt. Phone

Paperless Billing

Yes

No

ADDRESS OF PROPERTY TO BE SERVED Check here if same as mailing address
Street Address

Unit #

City

Nearest Cross Street

Special Instructions

Zip

PRIMARY SITE USE
RESIDENTIAL

COMMERCIAL

PUMPING

LIGHTING

Single House

Apartment

Store

Warehouse

Agricultural

DD Light (150 Watt)

Duplex

Mobile

Office

Restaurant

Non-Agricultural

DD Light (250 Watt)
Qty

Other

Other
Additional site information:

SERVICE SPECIFICATIONS (See Note 1 and Note 2 on page 2)
Project Name (if applicable)

Overhead

120/240V 1Ø phase, three wire
Load

Amps

120/208V 3Ø phase, four wire
Capacity

Underground

277/480V 3Ø phase, four wire
kVA

Total hp Motors

hp

Additional Information for design consideration:

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BIA-DWP-PWR-101
Rev. 01/12/2022

OMB Control Number: 1076-0021
Expiration Date: XX/XX/XXXX

ELECTRIC SERVICE APPLICATION
Request for Taxpayer Identification Number: In accordance with the Debt Collection Act of 1996, you are required to provide your taxpayer
identification number. This number may be used to make payments (refunds) or for purpose of collecting and reporting on any delinquent amounts
arising out of your relationship with the Federal Government.
The Privacy Act, as amended, authorizes the collection of this information, The primary use of this information is to identify the recipients of electrical
utility service. Disclosures of Information may be to: U.S. Department of Justice or in a proceeding before a court or adjudicating body; Federal, state,
local, or foreign law enforcement agency; Members of Congress; Department of Treasury to effect payment; Federal agency for collecting a debt; and
other Federal agencies to detect and eliminate debt.
Paperwork Reduction Act Statement: This information being collected is required under the Debt Collection Improvement Act of 1996 from
individuals and businesses doing business with the government. This form is covered by the Paperwork Reduction Act. It is used to establish the nature
and amount of a claim the respondent can make against the Federal government. The information is provided by respondents to obtain or retain a
benefit. Public reporting burden for this form is estimated to average 30 minutes per response. Direct comments regarding the burden estimate or any
other aspect of this form to Attn: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.
Note: comments, names and addresses of commentators are available for public review during regular business hours. If you wish us to withhold this
information you must state this prominently at the beginning of your comment. While you can ask us in your comment to withhold your personal
identifying information from public review, we cannot guarantee that we will be able to do so. A federal agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The number and expiration date are
displayed in the upper right corner of the form.
Note 1: For services requiring construction, allow a minimum of eight weeks for engineering and design. After full payment is received, allow a
minimum of six weeks for start of construction. In addition to deposit and connection fees, a construction advance payment may be required before
installation can be made; electric lines extended; DD light(s) installed or service connected.
Note 2: All customer-owned wires and equipment must be inspected by the appropriate governing building safety authority and a clearance provided to
the utility before electric service can be connected for any of the following: (1) New service (2) Service is disconnected for the purpose of maintenance,
relocation, or upgrades to the customer’s side of the meter OR (3) Service is turned off for a period of six months or longer. Exceptions: Seasonal
customers may be extended to twelve months in accordance with the providers operational manual.
Life Support Certification: Most power outages are caused by unpredictable events such as wind, lightning, accidents or wildlife. Please make
preparations for unpredictable power outages. We encourage customers to install a battery back up system to power life support devices, monitors and
other related systems. A medical form on file does not guarantee your service will not be disconnected for unpaid electric bills and medical accounts
are subject to the same bill payment terms as other accounts. Before disconnection of service occurs, please contact us to determine if a payment
arrangement is available. A medical form is available to all customers that need essential medical equipment in their home to sustain life. The medical
form must be completed by both the customer and the customer’s physician. Please complete and email the form back to your respective utility.
CHECK IF APPLICABLE

Applicant’s Name

Applicant’s Name

(Please Print)

Signature

Signature

Date

Date

(Please Print)

*** Office Use Only ***

Check/MO #
Account No.

Revenue Class

Location No.

Service Rates

Security Deposit
Connection Fee
Other Fees

Lighting Rate

Number of Lights

Billing Preference

eBill

Paper

Medical Exemption

Total Fees

Type:
Yes

No

Date of Receipt

Completed By

Approval By

Date

Date
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