AUTHORIZATION TO RECEIVE CUSTOMER'S HISTORICAL USAGE INFORMATION

AUTHORIZATION TO: RECEIVE CUSTOMER'S HISTORICAL USAGE INFORMATION
I,
NAME
OF
NAME OF CUSTOMER OF RECORD
HAVE THE FOLLOWING MAILING ADDRESS

MAILING ADDRESS

Street Address Line 2

CITYSTATE

Postal / Zip Code
DO HEREBY APPOINT
NAME OF THIRD PARTY
OF

MAILING ADDRESS

Street Address Line 2

CITYSTATE

Postal / Zip Code
TO ACT AS MY AGENT AND CONSULTANT (AGENT) FOR THE LISTED ACCOUNT(S) AND IN THE CATEGORIES INDICATED BELOW:
ACCOUNTS INCLUDED IN THIS AUTHORIZATION:
1. SERVICE ADDRESS
CITY
SERVICE ACCOUNT NUMBER
2. SERVICE ADDRESS
CITY
SERVICE ACCOUNT NUMBER
(FOR MORE THAN TWO ACCOUNTS, PLEASE LIST ADDITIONAL ACCOUNTS ON A SEPARATE SHEET AND ATTACH IT TO THIS FORM)
I
(CUSTOMER)
AUTHORIZE MY AGENT AND HIS CONTRACTORS TO ACT ON MY BEHALF TO PERFORM THE FOLLOWING SPECIFIC ACTS AND FUNCTIONS:

REQUEST AND RECEIVE BILLING RECORDS, BILLING HISTORY AND ALL METER USAGE DATA USED FOR BILL CALCULATION FOR ALL OF MY ACCOUNT(S) AS SPECIFIED HEREIN, REGARDING UTILITY SERVICES FURNISHED BY THE UTILITY.

AUTHORIZATION IS GIVEN FOR THE PERIOD COMMENCING WITH THE DATE OF EXECUTION UNTIL:
Date

MonthDayYear
Date
REQUEST FOR INFORMATION AND/OR FOR THE ACTS AND FUNCTIONS SPECIFIED ABOVE WILL BE ACCEPTED AND PROCESSED EACH TIME REQUESTED WITHIN THE AUTHORIZATION PERIOD SPECIFIED HEREIN.
AUTHORIZED CUSTOMER SIGNATURE
TELEPHONE NUMBER
Format: (000) 000-0000.
EXECUTED THIS
DAY
OF
MONTH
YEAR
AT
CITY AND STATE WHERE EXECUTED
ADDITIONAL ACCOUNTS

IF APPLICABLE
Cancelof
Should be Empty:

AUTHORIZATION TO: RECEIVE CUSTOMER'S HISTORICAL USAGE INFORMATION