Residential Electricity Service Request Form

Champion Energy Services is a great choice!

To get started with lower rates and better service, please complete the form below.

Customer & Billing Information
First Name: *
Last Name: *
Phone: *
Date of Birth:    
Drivers License #: *
Soc sec #:
*
Email: *
Service Address: *
Apartment #:
City:
State:
Zip:

Billing Address
  *
City:
State: *
Zip: *
Service Information
What type of service do you need?
Enter ESI ID: What's this? *
 
How did you hear about us?
Type of Dwelling?
# of Bedrooms?
Authorization
I have reviewed and understand the terms of service and conditions outlined in the contract above for my service address.
I would like to receive a copy of the Terms of Service Agreement by US Mail.
I prefer to receive correspondence in Spanish.
Please send me updates and special offers by e-mail.
Check this box to attest that a person at this location uses critical life support equipment. I further understand that I will have to complete an affidavit to affirm this.
Authorization Signature Required: By typing my name in the box provided below, I certify that I am at least 18 years old and legally authorized to select a retail electric provider for the service address above. I am also aware that a credit check may be performed as a determinant for deposit waiver.
Name: Enter full name as it appears above: