First Name:
Middle Initial:
Last Name:
Street Address:
Service Address cannot be a P.O. Box.
City:
State:
Arkansas
Oklahoma
Zip:
Home Phone:
E-mail:
Verify E-mail:
If your mailing address is different from the service address fill out the following:
Mailing Address:
City:
State:
Arkansas
Oklahoma
Zip:
Social Security:
Drivers License Number:
Employer:
Spouse/Co-applicant Name:
Spouse/Co-applicant SSN:
Landlord:
Status:
Married
Single
Is service currently ON for this location?
Yes
No
Unknown
Start Service Date:
AOG will call and confirm the schedule date/time.
Requested By:
Comments:
Note: Oklahoma residents will be billed a $25 connection fee on all new accounts. Arkansas residents will be billed a $25 connection fee on all new accounts. In addition, a security deposit may be required for Oklahoma and Arkansas residents.
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