Financial Authorization Form - Puget Sound Energy
[Pages:1]Financial Authorization Form
Service Location for Move In: Applicant Name: ______________________________________________________________________ Co-Applicant Name: ___________________________________________________________________ Street Address: _______________________________________________________________________ City: __________________________ State: __________________ Zip Code: _____________________ Date of Responsibility: ___________________ Email: ________________________________________ Mailing Address (if different):____________________________________________________________ City: __________________________ State: __________________ Zip Code: _____________________ Contact Phone Numbers(s): ____________________________________________________________
Residential Provide One: Last Four SSN, Full DOB, Driver's License #, Passport #, Military ID Commercial Provide both: UBI and Tax ID (include state) _________________________________________________________________________ I confirm by signing this authorization form, I agree and acknowledge that I am applying for utility service with Puget Sound Energy and am responsible for any charges incurred at the location listed above.
Applicant Authorization Signature: _______________________________________________________ Co- Applicant Authorization Signature: ___________________________________________________ Applicant Authorization Name: __________________________________________________________ Co-Applicant Authorization Name: _______________________________________________________ Signature Date:______________________________________________________________________
Complex/Management/Owner Name: ____________________________________________________________________________ Contact Phone Number(s): ____________________________________________________________ Email: _____________________________________________________________________________
03-02-2015
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