Broker Registration
Contact
Company Legal Name *
Company Federal Tax ID
Company Web Address
* Contact Person (First and Last Name)
* Address
* City
* State
* Zip Code
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
* Main Phone
Extension is optional
* Cell Phone
* Primary Email
Questions
* How many employees does your company directly employ?
* How many years of experience do you and your company have in the retail energy industry?
You
Company
* How many years of experience do you and your company have as a retail energy broker?
You
Company
* Does your company offer other business services? If yes, please explain.
No
Yes
* What is your average size (kWh annually) of your customer base?
* How many customers do you have under contract?
Residential
Commercial
* In which states do you sell retail energy to customers? For each state, please provide your PUC broker license or certification number. If the state does not have one, please enter "none".
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
* Have you, any of your company's employees, or subcontracts been subject to disciplinary or enforcement action by any state regulatory body within the last 5 years. If yes, please explain.
No
Yes
* Have you or your company ever been the subject of any Better Business Bureau complaints? If yes, please explain.
No
Yes
* Have you, any direct or indrect owners/principals of your company, or your company ever been charged with, or convicted of, a felony crime or any crime involving moral turpitude? If yes, please explain.
No
Yes
* Would you authorize NextEra Energy Services and/or Gexa Energy to conduct a background investigation on you and/or your company?
No
Yes
What are your interests (golf, sporting events, concerts, skiing, etc.)?
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