Application Form For Parties Wishing To Offer, Render, Furnish, Or Supply Electricity Or Electric Generation Services To The Public In The Commonwealth Of Pennsylvania Page 4

BEFORE THE PENNSYLVANIA PUBLIC UTILITY COMMISSION

Application of ___________________________, d/b/a __________________________, for approval to offer, render,

furnish, or supply electricity or electric generation services as a(n)__[as specified in item #4b below] to the public in

the Commonwealth of Pennsylvania (Pennsylvania).

To the Pennsylvania Public Utility Commission:

IDENTIFICATION AND CONTACT INFORMATION

a. IDENTITY OF THE APPLICANT: Provide name (including any fictitious name or d/b/a), primary address, web

address, and telephone number of Applicant:

b. PENNSYLVANIA ADDRESS / REGISTERED AGENT: If the Applicant maintains a primary address outside

of Pennsylvania, provide the name, address, telephone number, and fax number of the Applicant’s secondary

office within Pennsylvania. If the Applicant does not maintain a physical location within Pennsylvania, provide

the name, address, telephone number, and fax number of the Applicant’s Registered Agent within

Pennsylvania.

c. REGULATORY CONTACT: Provide the name, title, address, telephone number, fax number, and e-mail

address of the person to whom questions about this Application should be addressed.

d. ATTORNEY: Provide the name, address, telephone number, fax number, and e-mail address of the

Applicant’s attorney. If the Applicant is not using an attorney, explicitly state so.

e. CONTACTS FOR CONSUMER SERVICE AND COMPLAINTS: Provide the name, title, address, telephone

number, FAX number, and e-mail of the person and an alternate person responsible for addressing customer

complaints. These persons will ordinarily be the initial point(s) of contact for resolving complaints filed with the

Applicant, the Electric Distribution Company, the Pennsylvania Public Utility Commission, or other agencies.

The main contact’s information will be listed on the Commission website list of licensed EGSs.

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