Residential Electricity Service Request Form

 

Green Mountain Energy Company is the nation’s leading retail provider of cleaner energy and carbon offset solutions.

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
Street: *
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: