Authorized Contact Agreement Form
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1Authorized Contact Agreement
An AUTHORIZED CONTACT is a person you allow Beltrami Electric Cooperative to give limited account
information. They will also have the ability to schedule payment arrangements on your account. This person will
not be allowed to make ANY changes to the account. (This includes requests for changes to the service status.)
To add an AUTHORIZED CONTACT(s), please enter all of the required information in the fields provided. Sign and
mail/fax or drop off the completed agreement to our office. (If there is a joint membership name, that person must also
sign the authorized contact agreement.)
_______________________________________________________________
Member Name:
First
Middle Initial
Last
Last 4 of Social Security Number:
___ ___ ___ ___
Date of Birth: ___ / ___ / ___
_______________________________________________________________
Joint Member Name:
First
Middle Initial
Last
Last 4 of Social Security Number: ___ ___ ___ ___
Date of Birth: ___ / ___ / ___
***************************************************************************************
An Authorized Contact will need to provide their date of birth and the last 4 of their SSN in order to
access account information at Beltrami Electric Cooperative, Inc.
***************************************************************************************
Please list the account number(s)
_____________________________________
_____________________
#1 Contact is Authorized for
Full Name of #1 AUTHORIZED CONTACT
Relation to member:
_______________________
_______________________
#1 Authorized Contact Date of Birth: ___ / ___ / ___
_______________________
Last 4 of Social Security Number: ___ ___ ___ ___
Please list the account number(s)
________________________________
_____________________
Relation to member:
#2 Contact is Authorized for
Full Name of #2 AUTHORIZED CONTACT
_______________________
_______________________
#2 Authorized Contact Date of Birth: ___ / ___ / ___
_______________________
Last 4 of Social Security Number: ___ ___ ___ ___
Authorized Contact Agreement forms will be used as a Third Party Notification form if one is requested during the Cold Weather Rule months.
Check box to have copies of disconnect notices sent to your designated Third Party.
***************************************************************************************
The signature(s) below grant permission to the above listed person(s) to receive limited access to
information contained on the account(s) specified as well as make payment arrangements. The addition
of an authorized contact does not grant any ownership to the unretired capital credits existing on
membership record.
**This agreement will remain in effect until Beltrami Electric is notified of its cancellation by the member(s)**
Signature of Member: _____________________________________
Date: ________________
Signature of Joint Member: _________________________________
Date: ________________
RETURN TO:
BELTRAMI ELECTRIC COOPERATIVE INC.
(218) 444-2540
Customer Service:
PO Box 488, Bemidji, MN 56619
(218) 444-3676
Fax Number:
Authorized Contact Agreement, August 2015
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