Membership Name Change

Request for Membership Change

Please complete the webform below OR the PDF here.

The undersigned does hereby release and surrender to Clark Energy Cooperative, Inc. all rights to Membership Certificate shown as:

Existing Membership Certificate

Name:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

The undersigned does hereby apply for membership as follows:

Requested Membership Certificate

Name:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

The undersigned also requests any capital credits and records associated with capital credits on the released certificate be assigned, transferred, and kept with the newly requested member certificate.

Member Signature

Sign above

Spouse Signature

Sign above

Member #:

Member's SS# (last four digits):

Spouse's SS# (last four digits):

Member's DL #:

Spouse's DL #:

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