Billing and/or Payment History Release Form

The Employers' Energy Alliance of Pennsylvania, Inc. (EEA-PA) is hereby authorized to request and receive billing and/or payment history for all of your account(s).

Company Name*

Primary Energy Contact *

E-mail*

Account 1 Information

Name of Utility*

Account Number*

Service Address*
(include city, state, zip)

Billing Address*
(include city, state, zip))

Only Utility accounts disclosed on this form will be processed in the Energy Program.

Please provide a copy of your most recent utility bill(s) for each account listed above.

I will email a copy of each utility bill to the attention of the EEA-PA at eeapa@mbausa.org or fax the information to 814-833-4844.*

I authorize my utility to respond to EEA-PA in matters pertaining to my account(s) noted above and to provide EEA-PA consumption history, billing, equipment, and service records along with payment history and any additional information deemed necessary by EEA-PA. This letter of authorization is valid for a period of not less than five consecutive calendar years, which begin with the customer's acceptance.*

(800) 815-2660

Billing and/or Payment History Release Form

Account 1 Information