Please fill out the following application and authorization form* indicates required fields Application Type: New Renewal Customer Location: Customer Name (Legal Entity Name): * D/B/A (if applicable): Name as it appears on current bill: Billing Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Check here if billing address is same as service address Authorized Customer Representative (the person signing the supplier contract): Name: * First Name Last Name Title: Phone Number: * (###) ### #### Email Address: * Alternate Customer Representative: Name: First Name Last Name Title: Phone: (###) ### #### Email: Current Contract Information: Is your account currently under contract with a supplier (not the utility): Electric Yes No N/A If yes, who is your current electric supplier: If yes, expiration date of current electric contract: Natural Gas: Yes No N/A If yes, who is your current natural gas supplier: If yes, expiration date of current natural gas contract: Please provide your current contract (or future) expiration date above to avoid any early termination fees from your current supplier. Authorization Form By Checking this box I understand the following: * The Customer hereby authorizes the local Energy Distribution Company (EDC) to permit supplier to directly receive Customer’s most recent twenty four (24) months electric or natural gas account data and twelve (12) months of payment history for the Account Numbers with meters located at the address shown in Step Two. This billing information may include information on service configuration and descriptions of previous energy use. Supplier has the right to use the information provided and to retain the information in their files, and disclose it to any authorized employee, agent, or representative. Supplier hereby agrees not to sell, or otherwise disclose, said information to any third party not authorized in writing by Customer for the purposes of such third party marketing to, or soliciting business from Customer. THE UNDERSIGNED HEREBY CERTIFIES THAT THE SIGNER IS AN AUTHORIZED REPRESENTATIVE OF THE CUSTOMER AND THAT THE INFORMATION PROVIDED HEREIN IS TRUE AND CORRECT AND ACCURATELY REFLECTS THE CUSTOMER’S CURRENT BUSINESS CONDITION. I HAVE READ THE STATEMENT ABOVE AND UNDERSTAND Name * Name of Authorized Representative First Name Last Name Title: * Date Approve: * MM DD YYYY Chamber of Commerce - Energy Cooperative Waiver By Checking this box I understand the following: * Our company understands that we will be entering into an agreement for electricity and/or natural gas with a supplier selected through a cooperative that will be coordinated on behalf of the membership by the Chamber of Commerce. We recognize that our company’s contract will be independent of the Chamber and that there could be some potential risk involved. As such, our company agrees to indemnify the Chamber from any and all liability, loss, or damages that may be suffered by our company as a result of participation in the cooperative. Our company agrees that we will maintain continuous membership in the Chamber of Commerce for the duration of the co-op contract with the supplier in order to participate in this cooperative initiative at special Chamber pricing rates. We understand that failure to maintain Chamber membership can and will jeopardize our participation in the renewal of future co-ops. We understand that this waiver must be signed and returned prior to joining the electricity cooperative at special pricing rates. Failure to sign this waiver will prevent our company from participating in this cooperative at special Chamber pricing Rates. The Applicant/Customer has read and understands the conditions for participating in this Chamber Cooperative Purchasing Program. I HAVE READ THE STATEMENT ABOVE AND UNDERSTAND Name: * Name of Authorized Representative First Name Last Name Title: * Company Name: * Date Approved: MM DD YYYY Please attach copies of bills here. Two bills for each account, all pages please. Also if you have current contracts please attach. File Format: .jpg, .jpeg, .png, .gif, .pdf FileField;MaxSize=10000;Multiple;addText=Upload_Bills_Here; Thank you!
