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Disclosure of Information to a Third-Party Consent Form

 If you have any questions about completing this form, please contact Customer Care  customercare@grandbridgeenergy.com or (519) 621-3530.

PART A: CUSTOMER INFORMATION

Please complete all applicable customer information in this section. 

PART B: CONSENT FOR DISCLOSURE OF INFORMATION TO THIRD PARTY

The above-noted customer hereby consents to the disclosure by GrandBridge Energy (formerly Energy+) of the following account related information to the Third-Party. 

THIRD-PARTY INFORMATION

This section outlines who GrandBridge Energy is authorized to release customer account information to.

The consent remains in effect from (please choose one):
 
Account-Related Information That Can Be Disclosed (please choose all that apply):
 
I hereby consent to the disclosure of information to the Third-Party named above. Where two parties are responsible for the account, both account holders must sign the consent before account information will be disclosed.
 
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