Authorization Form To Release Customer Information To A Third Party printable pdf download

Authorization Form To Release Customer Information To A Third Party

AUTHORIZATION FOR FORTISALBERTA INC. TO RELEASE CUSTOMER INFORMATION TO A THIRD PARTY AND

CUSTOMER CONSENT AND APPROVAL FOR A THIRD PARTY TO ACT ON CUSTOMER’S BEHALF

_________________________________________ (the “Customer”), hereby directs and authorizes FortisAlberta Inc. to

provide Customer-related information, (the “Customer Information”), which may include personal information and

proprietary business information as the case may be, to:

__________________________________________________________________________________________________

______________________________________________________________________ and its employees, consultants,

contractors and agents (the “Third Party’), and the Customer furthermore provides its consent and approval for the

Third Party to provide instructions on behalf of the Customer to FortisAlberta Inc. relating to the Customer. Unless

advised by the Customer in writing the timeframe respecting this authorization shall be for two (2) years from the date

of this authorization.

With respect to all of the aforementioned, the Customer hereby agrees to indemnify hold harmless and absolutely and

unconditionally release FortisAlberta Inc., its affiliates, officers, directors and employees of and from any liability and

any and all form of claim as might arise out of, result from, or in any way relate to the dissemination, sharing or use of

the Customer Information by FortisAlberta Inc. with the Third Party pursuant to this authorization.

The Customer understands that the authorization may be revoked by the Customer at any time by providing written

notice to FortisAlberta Inc.

UNDERSTOOD, ACCEPTED and AGREED this ___ day of __________ 20__.

___________________________________

Signature

___________________________________

Print Name

___________________________________

Title

_____________________________________________________________________________________

Company

Address

_____________________________________________________________________________________

Phone

Cell

Please Email or Fax this completed form to: FortisAlberta Inc. Attention: Customer Connections

Email:

Fax Number: 403-514- 4415

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Authorization Form To Release Customer Information To A Third Party