Avalon Energy Services, LLC
Authorization to Release Natural Gas Billing and Payment Data
The undersigned Customer hereby authorizes Avalon Energy Services, LLC (Avalon) and its third-party suppliers to receive Customer’s most recent twenty-four (24) months of natural gas usage, billing, payment data and rate class for the accounts listed below or attached.
Customer ___________________________________________________
Customer’s Title ___________________________________________________
Company (legal name) ___________________________________________________
Address ___________________________________________________
City, State, Zip ___________________________________________________
Telephone and Extension ___________________________________________________
Fax ___________________________________________________
email address ___________________________________________________
Customer’s Signature, Date ________________________________ _______________
Account Number Service Address Utility Identification Number
__________________ ____________________________ __________________________
__________________ ____________________________ __________________________
__________________ ____________________________ __________________________
__________________ ____________________________ __________________________
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