Residential Electricity Service Request Form

With Dynowatt Power you get "Your Electricity. Your Way."

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

same as above

Street:

City:

State:

Zip:

Credit Card Information

A credit card number is required for service with Dynowatt. After a review of your credit history, Dynowatt will determine whether or not a deposit is needed for service. Please enter your credit card information below, in case a deposit is required for service.

Credit Card Type:

Credit Card Number:
Without dashes or spaces

Credit Card Security Code:

* What is this?

Expires:

Month: Year:

Name:
As it appears on your credit card

Billing Address:
Must match the address on your credit card statement

City:

State/Province:

Zip/Postal Code:

Country:

Service Information

What type of service do you need?

Enter ESI ID: What's this?

I don't know my ESI ID.

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:

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