Name(Required) First Last HiddenMember Number OLDMeter Number Work Order NumberSubdivision and Lot Number(Required) Service Address(Required) Street Address Address Line 2 City State 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 ZIP Code Phone(Required)Email(Required) Consent(Required) I, the undersigned, a member of Bartholomew County REMC, in consideration of membership and as an enticement to Bartholomew County REMC for performing underground service and/or repair of its facilities for service to me and others so as to avoid damage to underground facilities of mine, do hereby agree to mark the location of such underground facilities of mine by using paint or other appropriate marking materials and/or markers, similar to flags, the location of such underground facilities no less than two days prior to trenching service to be performed by Bartholomew County REMC or its representatives. I understand I will be notified a reasonable period of time by Bartholomew County REMC of their planned construction/trenching in order to meet this time table. I am familiar with the excavation required to install underground cable and understand that while REMC will backfill once after installation, I am responsible for any further restoration. I hereby waive any right or claims against Bartholomew County REMC or its representatives for digging or trenching in or around said areas where in so doing it relied upon my markings and identification as to the location of such underground facilities. I hereby verify the information to be true and complete. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.PhoneThis field is for validation purposes and should be left unchanged.