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2. First Name*
   Account Holder Information
3. Last Name*
5. Address1*
7. Address2
9. City*
10. State*
11. Zip*
13. Phone Number*
14. Email Address*
16. Account Number*
17. Customer Number
19. Estimated Monthly kWh Usage
20. Language Preference*
    (English, Spanish, or Other)
22. After submitting this form, your information will be provided to our third party contractor, Synergy Companies. Synergy will contact you directly to set up an appointment for the audit. Please allow 10-14 days for a representation to reach out to you.
24. For more information or if you have any questions, please contact the Electric Department at (909) 514-4214.
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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