Job Information

State:

City:

House/ Building Number :

Lot Number:

Street Name:

Cross Street:

Zip Code:

Your Name :

Streetlight Type

Public Private Highway

Job Type:

Construction Type:

Area Lighted

Public Private

Service Type:

Customer Type:

Brief Description of Work:

Pole Number:

Development Name:

Number Of Lots:

Location Description:

Problem Type:

Additional Location Information:

Premium Decorative:

Yes No

Circuit Number:

Project Id:

Customer Information

Customer First Name:

Customer Last Name:

Business Name:

Address Type:

House /Building Number:

Street Name:

Street Type:

Apartment/Unit Number:

City:

State:

Zip Code:

P.O. Box:

Primary Phone:

Mobile Phone:

Email:

Preferred Contact Method:

Account Number:

Where did you hear about us:

Specify Contact Method:

Load Breakdown

Single Phase(kW)

(All values to be entered in kW)

Lighting:

Electric Heat:

Air Conditioning:

Refrigeration:

Cooking:

Electric Dryer:

Water Heater:

Process Equipment:

Motors/Elevators:

Electric Vehicle Charger:

Miscellaneous Load:

TOTAL (kW):

Three Phase(kW)

(All values to be entered in kW)

Lighting:

Electric Heat:

Air Conditioning:

Refrigeration:

Cooking:

Electric Dryer:

Water Heater:

Process Equipment:

Motors/Elevators:

Electric Vehicle Charger:

Miscellaneous Load:

TOTAL (kW):

Operating Characteristics

Normal Operating (30 MIN kW):

Normal Operating (Hrs/Mo):

Normal Operating (kWh):

Total Operating (Sum of 30 MIN kW Demand):

Controller Wattage:

Lamp Wattage:

Number of Signs:

Flashing Operating (30 MIN kW):

Flashing Operating (Hrs/Mo):

Flashing Operating (kWh):

Total Operating (Sum of Monthly KWh):

Number of Ways:

Number of Arrows:

Number of Walks:

Contractor/Electrician Information

Primary Contact and Billing

Primary Contact

Monthly Bill

Construction Charges

Requested Completion Date

Requested Completion Date:

Entering a date provides us with a timeline only - it does not confirm that the work will be performed or completed by that date.

Documents

Filename	Description	Size	Created