Fuel Release Authorization Form July 1, 2015

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Other __________________________________________________________
Fuel Release Authorization Form
July 1, 2015 - June 30, 2016
Property Information
Property Name
City
Property Address
State
Contact Name
Contact Phone
Contact E- mail
Designated Representative for Info Release
Contact Phone
Contact E -mail
Energy Provider Information
Electric Utility Company
Electric
Account Name
Zip
Account Number
Account Mailing Address (if different from above)
City
State
Zip
State
Zip
State
Zip
State
Zip
Other account numbers associated with this facility:
(Additional space is provided on page two of this form to include other locations.)
Okay To Release Cost Information
Natural Gas
Account Name
Natural Gas Utility Company
Account Number
Account Mailing Address (if different from above)
City
Other account numbers associated with this facility:
(Additional space is provided on page two of this form to include other locations.)
Okay To Release Cost Information
Oil Supplier
Account Name
Other
Oil Supplier Name
Account Number
Account Mailing Address (if different from above)
City
Energy/Resource Provider
Account Number
Propane, Steam, Chilled W ater, Etc.
Account Name
Account Mailing Address (if different from above)
City
By signing this form, I hereby authorize New Jersey Clean Energy Program (NJCEP) or its designated representative, to obtain energy usage data, on my behalf, regarding
my facility past and present energy usage for the purpose of benchmarking and/or auditing my facility energy usage efficiency. This data shall be kept confidential and shall
not be shared with any third parties, other than those designated by NJCEP for management of its energy efficiency programs. The data shall not be published or used for any
other purpose without my expressed written consent.
Name of Authorized Representative (please print)
T itle
Signature
Date
001 7-1-15
Other facility locations to include in fuel release authorization:
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number
Address
Electric Account Number
Natural Gas Account Number