The Undersigned owner hereby makes application for temporary electric service for building purposes prior to wiring of the premises located in Section ________________ Township _______________, Range _______________, in the County of __________________ Wisconsin/Michigan.

The Undersigned owner warrants that said premises will be wired in accordance with National and State electrical codes and the safety requirements of the Rural Electrification Administration.

The Undersigned owner will submit a notarized affidavit of wiring upon completion of the wiring and the owner hereby releases the Cooperative from any and all liability of every kind and nature for damage which may occur from defective wiring of said premises.

The owner hereby agrees to install approved type fusing and an approved type weatherproof outlet below the meter for the protection of the Cooperatives' and the owner's equipment.

Dated this __________ day of ______________ 20______

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Owner's Signature

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Route and/or Box Number

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