Authorization To Receive Customer Information Or Act On A Customer'S Behalf Page 2
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1
2AUTHORIZATION TO: RECEIVE CUSTOMER INFORMATION OR ACT ON A CUSTOMER’S BEHALF
I (CUSTOMER) AUTHORIZE THE RELEASE OF MY ACCOUNT INFORMATION AND AUTHORIZE MY AGENT
2
TO ACT ON MY BEHALF ON THE FOLLOWING BASIS
(initial one box only):
One time authorization only (limited to a one-time request for information and/or the acts and functions
Secified 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 use 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
2
If no time period is specified, authorization will be limited to a one-time authorization.
Form 14-796
Page 2 of 2
4/2011
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