CREDIT CHECK REQUEST

Please complete the following information and return to Homer Electric in person, submit electronically
or fax to the Homer (907-235-3345) or Kenai (907-283-2353) offices.
HEA MEMBER INFORMATION
Member #: / Single Joint
Member Name:
Last / First / Middle
Member SS#: / - / -
Joint Member Name:
Last / First / Middle
Joint Member SS #: / - / -
Mailing Address:
Street / City / State / Zip
Home Phone: / Business Phone: / Cell Phone:
By signing below, I authorize Homer Electric Association to conduct a Credit Check:
Member Signature / Date / Joint Member Signature / Date
Member Name (Please Print) / Joint Member Name (Please Print)
CO-SIGNER INFORMATION (if applicable)
Co-Signer Name:
Last / First / Middle
Mailing Address:
Street / City / State / Zip
Home Phone: / Business Phone: / Cell Phone:
Co-Signer SS#: / - / -
By signing below, I agree to co-sign for the applicant(s) above and authorize Homer Electric Association to conduct a Credit Check:
Co-Signer Signature / Date / Co-Signer Name (please print)
FOR HEA PERSONNEL USE ONLY:
LOC / Other / APPROVED: Retailer Equipment AMOUNT Requested: / $
Credit Check Request by: / Active LOC: / LOC Balance: / $
Initial / Date/Time
HEA Credit History : / Comments:
Terms: / Months
Late Pay / # of Months / Active Accounts / CC / BD / Installments: $

- FOR MEMBER SERVICES DEPARTMENT ONLY-

$1500.00 or LESS / Credit Disapproved / Credit Approved
Amount Approved / $ / Interest Rate / % / Loan Terms
UPN Update & Customer Notification
Authorized HEA Representative / Date
Audit By

-SUPERVISOR REVIEW-

Credit Disapproved / Credit Approved
Amount Approved / $ / Interest Rate / % / Loan Terms
UPN Update & Customer Notification
Authorized HEA Representative / Date

HEA Form #0071 (Revised 4-1-16) Page 2 of 2