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Member  Information Applicant’s Full Name: ____________________________________________ SS#: ______________________ Date of Birth: _______________ Have you ever had service with PRECorp? NO

YES

Home Phone: ___________________ Cell Phone: ____________________ E-mail address: ________________________________________ Best phone number(s) to reach you in the event of a power outage: _______________________________________________________ Mailing Address: __________________________________________________________________________________________________________ Previous Address: ________________________________________________________________________________________________________ Bank or Credit Union: ______________________________________________________________________________________________________ Applicant’s Employer: ________________________________________________________________ Phone: ____________________________ Spouse/Roommate’s Name: ________________________________________SS#:________________________ Date of Birth: ________________ Spouse/Roommate’s Employer: _________________________________________________________ Phone: ___________________________ List Two Relatives or Friends who do not live with you: 1. _______________________________________________________________________________________________________________________ NAME RELATIONSHIP ADDRESS PHONE 2. _______________________________________________________________________________________________________________________ NAME RELATIONSHIP ADDRESS PHONE Property Owner: _____________________________________Address: _______________________________________Phone: ______________

Account information will not be provided to anyone other than the account holder(s) without written authorization from account holder(s). If applicable, please list others (spouse, roommate, family members) you authorize PRECorp to release your account information: ______________________________________________________________________________________________________________________________ Is there a DISABILITY or LIFE THREATENING CONDITION that requires electricity? NO

YES

(If yes, please explain.)

_______________________________________________________________________________________________________________________ +H[GU[QWYKNNPGGFVQRTQXKFG24'%QTRYKVJCYTKVVGPUVCVGOGPVHTQO[QWTRJ[UKEKCPVQDGRNCEGFKP[QWTĆœNG 2QYFGT4KXGT'PGTI[%QTRQTCVKQPYKNNOCMGGXGT[GĆ›QTVVQTGUVQTGGNGEVTKECNUGTXKEGCUUQQPCURQUUKDNGFWTKPICPQWVCIG6JGTGKUPQ guarantee the power will be restored within a given time frame. Individuals are responsible to have an alternative if power cannot be restored before any condition becomes critical.

+CWVJQTK\GCP[JQNFGTQHKPHQTOCVKQPTGICTFKPIVJGĆœPCPEKCNUVCVWUQTEQNNGEVKQPQHO[CEEQWPVKPENWFKPIGORNQ[OGPVXGTKĆœECVKQPVQ release said information to Powder River Energy Corporation.

Signature: _________________________________________________________________ Date: _______________________________________

SUNDANCE – CORPORATE HEADQUARTERS /CKP5VTGGVr21$QZr5WPFCPEG9;

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GILLETTE )CTPGT.CMG4QCFr21$QZr)KNNGVVG9;

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www.precorp.coop

SHERIDAN $TWPFCIG.CPGr21$QZr5JGTKFCP9;

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