PhoneThis field is for validation purposes and should be left unchanged.I, on behalf of myself or as an authorized agent of and on behalf of the Cooperative Member (“Applicant”), make application for the following proposed interconnected Distributed Resources facility that will be:Proposed Interconnected Distributed Resources Facility Type(Required) Owned by the Applicant Leased by the Applicant* Applicant/Authorized Agent Name(Required) First Last Cooperative Member Name(Required) First Last Cooperative Member Number(Required)Distributed Resources FacilityApplicant’s proposed interconnected Distributed Resources facility will have an installed capacity in kW and the following source(s) for electric power (check all applicable):Installed Capacity (kW)(Required)Source(s) for Electric Power Solar Wind Hydroelectric Geothermal Biomass Fuel-fed generator Energy storage devices (ex. Battery, Pump Storage, Flywheel) Other If other, describe:(Required)Estimated DatesApplicant’s proposed interconnected Distributed Resources facility’s estimated dates are as follows:Estimated Installation Date (MM/DD/YYYY)(Required) Month Day Year Estimated In-Service Date (MM/DD/YYYY)(Required) Month Day Year LandLatitude and Longitude Coordinates(Required)Applicant's proposed interconnected Distributed Resources facility will be on the following land. (describe by specific latitude and longitude coordinates) Land Ownership(Required) Owns in own name Leases from a third party ConstructionApplicant's proposed interconnected Distributed Resources facility will be constructed as follows (check 1):Construction Type(Required) As an attachment to an existing or to-be-built residential structure (“residential structure” is defined as a one- or two-family dwelling or townhouse) As an attachment to an existing or to-be-built non-residential structure As a stand-alone unit or structure (“structure” is defined as “that which is built or constructed”) Other Applicant Email(Required)Applicant’s email is for purposes of receiving communications from the Cooperative. Enter Email Confirm Email Consent Applicant Acknowledges That: Applicant has either received a copy of or been free to view the Cooperative’s IDR Policy, including all of its attachments, on the Cooperative’s webpage. Applicant is a member in good standing of the Cooperative and not a public utility. Applicant must execute a separate version of this Application and Acknowledgement Form and tender payment of the required application fee and any required non-refundable deposit for each different interconnected Distributed Resources facility (whether difference is by ownership or leased status, location, energy source, or installed capacity) that Applicant is considering and in order to commence the application process with respect to any and each interconnected Distributed Resources facility. Applicant will at all times fully comply with the Cooperative’s IDR Policy and all applicable state and federal rules and requirements, and timely pay any fees, deposits, charges called for thereunder. Regardless of where it is constructed, if its proposed interconnected Distributed Resources facility is constructed as either a stand-alone unit or structure or as an attachment to a non-residential structure, Applicant will provide the Cooperative with a color copy of its Permit (see Arkansas Fire Prevention Code, Vol. II, section 105) at the time the Eligible Member demonstrates to the Cooperative that the Distributed Resources facility is first ready for interconnection, in aid of satisfying Applicant’s burden and responsibility to demonstrate that the facility has been capably developed and constructed, of which the Cooperative is the sole judge. If its proposed interconnected Distributed Resources facility is constructed in a town, city, or county with a Building Official (as defined in the Arkansas Fire Prevention Code), Applicant will provide the Cooperative with a color copy of its Permit (see Arkansas Fire Prevention Code, Vol. II, section 105; Vol. III, section R105) and a color copy of its Certificate of Occupancy (see Arkansas Fire Prevention Code, Vol. II, section 111; Vol. III, section R110) at the time the Eligible Member demonstrates to the Cooperative that the Distributed Resources facility is first ready for interconnection, in aid of satisfying Applicant’s burden and responsibility to demonstrate that the facility has been capably developed and constructed, of which the Cooperative is the sole judge. If Applicant intends to lease the interconnected Distributed Resources facility from a third party, Applicant has attached hereto the lease* that will be or has been signed for the interconnected Distributed Resources facility, in aid of satisfying Applicant’s burden and responsibility to demonstrate that the facility will be capably developed, constructed and operated, maintained and repaired, of which the Cooperative is the sole judge. If Applicant owns the land on which the interconnected Distributed Resources facility is constructed, Applicant has attached hereto a copy of a current year property card for the land from the County Assessor’s office confirming that the land is owned by Applicant. *** If Applicant leases the land on which the interconnected Distributed Resources facility is constructed, Applicant has attached hereto a copy of the lease granting Applicant legal rights to use the land for installation and operation of an interconnected Distributed Resources facility, in aid of satisfying Applicant’s burden and responsibility to demonstrate that the facility will be capably developed, constructed and operated, maintained and repaired, of which the Cooperative is the sole judge. Applicant agrees that any Standard Interconnection Agreement that Applicant signs with the Cooperative will terminate on the same date as the lease termination date described in the attached lease. I hereby verify the information to be true and complete and agree to the termsand conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.If Applicant is an Individual - Signature (Full Name)(Required)If Applicant is Not an Individual - Applicant/Authorized Agent Signature (Full Name)Title or Basis of Legal Authority to Sign on Behalf of the Applicant* Specific dollar figures within this lease may be blacked out because they are not needed for purposes of the Cooperative’s review. *** Specific dollar figures within this lease may be blacked out because they are not needed for purposes of the Cooperative’s review.
