Credit Card Only Account Application

5053 Langston Blvd Arlington, VA 22207

Phone: (703) 536-4400; Email: DOM-AR@borderstates.com

Cash Account Application

By signing this form you give DOMINION ELECTRIC SUPPLY - A Division of Border States permission to authorize the person below to access account activity/information through our website www.dominionelectric.com.

Date

Business Name

Billing Address

Address Line 1

City

State

Zip Code

Requested By:

Phone

Please complete the information below:

Your information will be kept confidential and will only be used by Dominion Electric for our internal purposes of serving you.

User Information

Authorized Username

Company Title

Phone

Fax

Supervisor/Manager (if applicable)

Access Available To USER (Please Check All That Apply)

Product Orders
Product Price Availability
Account Status
Account History

Name

First

Last

Title

Signature

Clear Signature

Date

Available Supervisor/Manager Requested

Dominion Use Only

Verified By

Received Date

Approved Date

Notes

Credit Card Only Account Application

Cash Account Application

Please complete the information below:

User Information

Dominion Use Only

Contact Us

Other Pages

Quick Links

Credit Card Only Account Application

Cash Account Application

Please complete the information below:

User Information

Dominion Use Only

Contact Us

Other Pages

Quick Links

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