Applicant's First Name Last Name

E-mail Address Daytime Phone

Jones-Onslow EMC Account Number

Please add my NC GreenPower contribution to my electric bill.

$4 a month
$8 a month
$12 a month
$20 a month

I understand that my participation in the North Carolina GreenPower program is completely voluntary and billing will begin on my next electric bill.

(Note: Nonpayment contributions will result in removal from the program.)

I have read and understand the above and authorize the billing of NC GreenPower charges on my electric account.