Any customer electing to opt in under section 4928.6614 of the Revised Code shall do so by providing a written notice of intent to opt in to the electric distribution utility from which it receives service and submitting a complete copy of the opt-in notice to the secretary of the public utilities commission. The notice shall include all of the following:

1. (A) A statement indicating that the customer has elected to opt in;
2. (B) The effective date of the election to opt in;
3. (C) The account number for each customer account to which the opt in shall apply;
4. (D) The physical location of the customer's load center.