AUTHORIZATION TO: RECEIVE CUSTOMER
INFORMATION OR ACT ON A CUSTOMER'S BEHALF
SUBMITTED TO THE FOLLOWING.
Please check all that apply:
PG&E
SoCalGas
SCE
SDG&E
THIS IS A LEGALLY BINDING CONTRACT--READ IT CAREFULLY
(Please Print or Type)
I
,
NAME
TITLE (IF APPLICABLE)
of
, (Customer) have the following mailing address
NAME OF CUSTOMER OF RECORD
, and do hereby appoint
MAILING ADDRESS
CITY
STATE
ZIP
Energy Professionals, LLC
of
13892 Harbor Blvd. #4a
NAME OF THIRD PARTY
MAILING ADDRESS
Garden Grove CA 92843
CITY
STATE
ZIP
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
STATE
ZIP
SERVICE ACCOUNT NUMBER
2.
SERVICE ADDRESS
CITY
STATE
ZIP
SERVICE ACCOUNT NUMBER
3.
SERVICE ADDRESS
CITY
STATE
ZIP
SERVICE ACCOUNT NUMBER
(For more than three accounts, please list additional accounts on a separate sheet and attach it to this form)
INFORMATION, ACTS AND FUNCTIONS AUTHORIZED
This authorization provides authority to the Agent. The
Agent must thereafter provide specific written instructions/requests (e-mail is acceptable) about the particular
account(s) before any information is released or action is taken. In certain instances, the requested act or
function may result in cost to you, the customer. Requests for information may be limited to the most recent 12
month period.
I, (Customer) authorize my Agent to act on my behalf to perform the following specific acts and functions:
( initial all applicable boxes )
1. 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
1
.
2. Request and receive copies of correspondence in connection with my account(s) concerning (initial all that apply):
a. Verification of rate, date of rate change, and related information;
b. Contracts and Service Agreements;
c. Previous or proposed issuance of adjustments/credits; or
d. Other previously issued or unresolved/disputed billing adjustments.
3. Request investigation of my utility bill(s).
4. Request special metering, and the right to access interval usage and other metering data on my account(s).
5. Request rate analysis.
6. Request rate changes.
7. Request and receive verification of balances on my account(s) and discontinuance notices.
1
The Utility will provide standard customer information without charge up to two times in a 12 month period per service account. After two requests in a
year, I understand I may be responsible for charges that may be incurred to process this request.
Revised 10/28/99
Page 1 of 2
AUTHORIZATION TO
:
RECEIVE CUSTOMER INFORMATION OR ACT ON A CUSTOMER'S BEHALF
I (CUSTOMER) AUTHORIZE THE RELEASE OF MY ACCOUNT INFORMATION AND AUTHORIZE MY AGENT TO
ACT ON MY BEHALF ON THE FOLLOWING BASIS
2
(initial one box only)
:
2
If no time period is specified, authorization will be limited to a one-time authorization
One time authorization only (limited to a one-time request for information and/or the acts and functions specified
above at the time of receipt of this Authorization).
One year authorization - Requests for information and/or for the acts and functions specified above will be
accepted and processed each time requested within the twelve month period from the date of execution of this
Authorization.
Authorization is given for the period commencing with the date of execution until ________________________
(Limited in duration to three years from the date of execution.) Requests 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.
RELEASE OF ACCOUNT INFORMATION
:
The Utility will provide the information requested above, to the extent available, via any one of the following. My
(Agent) preferred format is (check all that apply):
Hard copy via US Mail (if applicable).
Facsimile at this telephone number:
Electronic format via electronic mail (if applicable) to this e-mail address:
I (Customer),
(print name of authorized signatory) , declare under penalty of
perjury under the laws of the State of California that I am authorized to execute this document on behalf of the Customer of
Record listed at the top of this form and that I have authority to financially bind the Customer of Record. I further certify that
my Agent has authority to act on my behalf and request the release of information for the accounts listed on this form and
perform the specific acts and functions listed above. I understand the Utility reserves the right to verify any authorization
request submitted before releasing information or taking any action on my behalf. I authorize the Utility to release the
requested information on my account or facilities to the above Agent who is acting on my behalf regarding the matters listed
above. I hereby release, hold harmless, and indemnify the Utility from any liability, claims, demands, causes of action,
damages, or expenses resulting from: 1) any release of information to my Agent pursuant to this Authorization; 2) the
unauthorized use of this information by my Agent; and 3) from any actions taken by my Agent pursuant to this Authorization,
including rate changes. I understand that I may cancel this authorization at any time by submitting a written request.
[This
form must be signed by someone who has authority to financially bind the customer (for example, CFO of a
company or City Manager of a municipality).]
______________________________________________________ ________________________
AUTHORIZED CUSTOMER SIGNATURE
TELEPHONE NUMBER
Executed this
day of
at
MONTH YEAR CITY AND STATE WHERE EXECUTED
I (Agent), hereby release, hold harmless, and indemnify the Utility from any liability, claims, demand, causes of action,
damages, or expenses resulting from the release of customer information obtained pursuant to this authorization and from the
taking of any action pursuant to this authorization, including rate changes.
_________________________________________________________ __________________________________
AGENT SIGNATURE TELEPHONE NUMBER
_________________________________________________________________________
COMPANY
Executed this
day of
MONTH YEAR
Revised 10/28/99
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