Safe to Energize Form

1. Customer Information

First Name *This question is required.

Last Name *This question is required.

Address of the Service *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

2. Contractor Information

Electrical Contractor Company Name *This question is required.

Contractor First Name *This question is required.

Contractor Last Name *This question is required.

Contractor License Number *This question is required.

Phone Number *This question is required. Example: 555-123-4567

Email Address *This question is required. This question requires a valid email address.

Electrical Inspection Number (if required)

Notes

3. Please acknowledge the following statement to proceed. *This question is required.

An inspection of the electrical service has been completed by a licensed electrician and the service is safe to energize at the above referenced address.