Applicant Information Applicant Name First Last Applicant Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Applicant Email Applicant Phone Primary Type - Type -HomeOfficeCell Phone Ext: Applicant Phone Secondary Type - Type -HomeOfficeCell Phone Ext: Applicant Membership Confirmation? Yes No Is the applicant a Mountain Parks Electric, Inc. Member? More Title Is the applicant a Mountain Parks Electric, Inc. Member? MPEI Account Number Other Contact Info Electrician Info Electrician Name First Last Suffix Electrician Phone Electrician Email Contractor Info Contractor Name First Last Contractor Phone Contractor Email Site Location Site Location, Within Town Limits Yes No More Is the building location within a town limit? Town Subdivision Lot, Block, Filing Building Site Address Section, Township, Range, and County of Building Site Attach a copy of Property Deed with Legal Description One file only.20 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, svg. Are all property corners clearly staked and labeled at the site? Yes No Light Type Request 100 Watt High Pressure Sodium 250 Watt High Pressure Sodium 400 Watt High Pressure Sodium LED Additional Remarks Site Sketch Attach a copy of the site sketch.One file only.20 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, svg. ELECTRONIC SIGNATURE (REQUIRED) Sign above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
