Disclosure of Information to a Third-Party Consent Form

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

PART A: CUSTOMER INFORMATION

Please complete all applicable customer information in this section.

Full Name of Customer:

Email:

Telephone:

Service Address:

City:

Province:

Postal Code:

Account Number:

Meter Number:

PART B: CONSENT FOR DISCLOSURE OF INFORMATION TO THIRD PARTY

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

THIRD-PARTY INFORMATION

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

Contact Name:

Business Name (if applicable):

Email:

Telephone:

The consent remains in effect from (please choose one):

The date of authorization of this form, to the date that written termination of the consent is received by Energy+.

The account is no longer in the account holder's name.

Specific to this one-time request only.

Account-Related Information That Can Be Disclosed (please choose all that apply):

Bill Account Information (including account holder name(s), address, telephone number, account notes, rates, rate pricing, billing, meter reading history)

Metering Information (including metering details, remote metering data)

Credit History and Payment History

Other

Please specify other information to be shared:

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.

Agree

Account Holder Name:

Name / Title of Authorized Person:

Account Holder Signature (For Corporations, signing authority certifies“ I have authority to bind the Corporation”):

Clear

Account Holder Name:

Name / Title of Authorized Person:

Account Holder Signature (if joint account):

Clear

Date:

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Disclosure of Information to a Third-Party Consent Form