Authorization for Additional Agent

White River Valley Electric Cooperative, Inc.

Authorization for Additional Contact/Agent - Commercial or Residential
Member/Business Name *
Social Security # or Tax Identification # *
Customer Number(s) *
Mailing Address *
City *
State *
Zip code *
I hereby authorize the following individual (s) to conduct business on my active account. I understand that written notice is required to revoke this authorization.
Authorized User # 1 *
Last Four Digits of SSN *
Telephone Number *
Phone number cannot start with 0 or 1.
Authorized User # 2
Last Four Digits of SSN
Telephone Number
Phone number cannot start with 0 or 1.
Authorized User # 3
Last Four Digits of SSN
Telephone Number
Phone number cannot start with 0 or 1.
Authorized User # 4
Last Four Digits of SSN
Telephone Number
Phone number cannot start with 0 or 1.
Authorized User # 5
Last Four Digits of SSN
Telephone Number
Phone number cannot start with 0 or 1.
Please verify: *
It is recommended that you print a copy of this Authorization for future reference.
Should be Empty:

White River Valley Electric Cooperative, Inc.