Registration Form Please forward this completed and signed application, and accompanying information to the following address
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- 630 Martin Luther King Boulevard
- Applicant Legal Name ____________________________________________________
- Telephone Number __________________ Fax Number _________________________
- ACH Instructions for Customer Remittances
- Conectiv Power Delivery EDI Worksheet
- Production System
 Maryland Electricity Supplier Registration Form Please forward this completed and signed application, and accompanying information to the following address: 
Co: Conectiv Power Delivery 630 Martin Luther King BoulevardPO Box 231Wilmington DE 19899-0231Attn: Scott C. RazzePlease provide the following information: 
Applicant / Company Applicant Legal Name ____________________________________________________Current Address ________________________________________________________________________________________________________City ________________________________________________State __________ Zip Code ____________________________Telephone Number __________________ Fax Number _________________________Federal Tax ID ______________________ D&B DUNS # ________________________PSC License # __________________________ PSC Certification Date ____________ PJM Supplier Short Name (6 chars or less): __ __ __ __ __ __ 
Banking Information ACH Instructions for Customer RemittancesBank Name _______________________ Address _____________________________ ABA #___________________________ City, State ___________________________ Account #_________________________ Zip Code ____________________________ Name on the account ________________ Contact at the bank ____________________ Phone # _____________________________ ACH Instructions for Settlement Payments (for potential future use) Bank Name _______________________ Address _____________________________ ABA #___________________________ City, State ___________________________ Account #_________________________ Zip Code ____________________________ Name on the account ________________ Contact at the bank ____________________ Phone # _____________________________ 
Supplier Contact Information Registration Contact: _____________________________ _________________________________ Last Name First Name Contact Phone Number: ( Extn: ___________ Email address: _________________________________________________________________________ Mailing Address: ______________________________________________________________________ City: ______________________________________ State: ________ Zip ______________________
Contact Phone Number: ( Extn: ___________ Email: ______________________________________________________
Supplier Name:____________________________________Phone Number:( Address: _________________________________________________________________________ City: ____________________________________________ State: _________ Zip: _________________ Supplier Billing contact information (for Conectiv billing to Supplier): Primary Billing Contact: _____________________________ _________________________________ Last Name First Name Contact Phone Number: ( Extn: ___________ Email address: _________________________________________________________________________ Mailing Address: ______________________________________________________________________ City: ______________________________________ State: ________ Zip ______________________
Retail Billing Contact: _____________________________ ____________________________ Last Name First Name Contact Phone Number: (______) Extn: ___________ E-mail address: ________________________________________________________________________
Primary Enrollment Contact: _____________________________ ____________________________ Last Name First Name Contact Phone Number: (______) Extn: ___________ E-mail address: ________________________________________________________________________ 
Conectiv Power Delivery EDI Worksheet
Contact Information
Test System
Production System
Filed with the Maryland PSC on 3/2/2000 Directory: newIntranet -> casenum casenum -> In a memorandum dated July 16, 2001, the Technical Staff of the Commission filed its comments regarding this matter. Staff noted that the loan would consist of two amounts: $10,233,000 to be obtained from rus casenum -> Mid-atlantic petroleum distributors association casenum -> Case No. 8509(z) casenum -> Reply brief of the staff of the maryland public service commission casenum -> Hearing examiner's notice of extension of filing date casenum -> Notice of revised procedural schedule casenum -> 630 Martin Luther King Boulevard po box 231 Wilmington de 19899-0231 casenum -> Baltimore Gas And Electric Company By casenum -> Request for investigation and petition for declaratory order against southern maryland electric cooperative, inc., Choptank electric cooperative and choptank home and business services, inc casenum -> Public Service Commission (Demand-Side Management) Download 68.16 Kb. Share with your friends:
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