Authorization for Additional Agent (03/2026)

White River Valley Electric Cooperative, Inc.

Authorization for Additional Contact/Agent - Commercial or Residential
Member/Authorized Name

First NameLast Name
Last Four Digits of SSN*
Business Name (If Applicable)
Last Four Digits of EIN*
Customer Number(s)*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone Number*
Format: (000) 000-0000.
Signature
Signature*
Date*

MonthDayYear
Date
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
Print Name*

First NameLast Name
Last Four Digits of SSN*
Signature
Signature*
Phone Number*
Format: (000) 000-0000.
Authorized User #2
Print Name

First NameLast Name
Last Four Digits of SSN
Signature
Signature
Phone Number
Format: (000) 000-0000.
Authorized User #3
Print Name

First NameLast Name
Last Four Digits of SSN
Signature
Signature
Phone Number
Format: (000) 000-0000.
Authorized User #4
Print Name

First NameLast Name
Last Four Digits of SSN
Signature
Signature
Phone Number
Format: (000) 000-0000.
Authorized User #5
Print Name

First NameLast Name
Last Four Digits of SSN
Signature
Signature
Phone Number
Format: (000) 000-0000.
Should be Empty:

White River Valley Electric Cooperative, Inc.