Information Authorization

Account #

Date

Single Membership First Name

Single Membership Last Name

Joint Membership First Name

Joint Membership Last Name

Authorization This document is to give authorization to the person listed below to be able to receive information about my account with West River Electric. This will include usage amounts, dollar balances, and make payment arrangements to the account. This person(s) will NOT have the authority to make changes to the account and cannot have a write off or uncollectable with WREA. This authorization is valid until it is revoked by the member. Name or names to authorize.

By Checking the BOX, I acknowledge that I am allowing the person(s) listed above to be able to receive information about my account with West River Electric, and by submitting this document electronically I understand that this is the legal equivalent of having placed my handwritten signature on the document.

Phone Number

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Pay By Phone: 605-791-6555