e-Bill Notification Member's Name* Phone*Account #* Location # Cycle # Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I, the undersigned member of Laurens Electric Cooperative, Inc. hereby request and make application to receive E-Bill notification via the internet. Conditions of This Agreement1. Please supply accurate e-mail address:* 2. Please check one:* would like to receive ONLY a mailed bill I would like to receive ONLY an emailed bill I would like to receive BOTH a mailed and emailed bill This Agreement Is Subject To Cancellation At Any Time Due To Any Of The Following: Termination of electric service by the undersigned at the location listed above. Member changes E-mail address without prior notifications of change. Thirty days written notice by either party. Signature*NameThis field is for validation purposes and should be left unchanged.