pdf form testing

Form No. 79-1095
Step 1 of 2
Name
NAME OF CUSTOMER OF RECORD
mailing address
city
State
zip
prefilled by sol power, INC.
name of third party
mailing
city
state
zip
To act as my agent and consultant (Agent) for the listed account(s) and in the categories indicated below: ACCOUNTS INCLUDED IN THIS AUTHORIZATION:
service address
city
Service Account Number
Service Address
city
Service Account Number
Service Address
city
Service Account Number
(For more than three accounts, please list additional accounts on a separate sheet and attach it to this form)
INFORMATION, ACTS AND FUNCTIONS AUTHORIZED – This authorization provides authority to the Agent. The Agent must thereafter provide specific written instructions/requests (e-mail is acceptable) about the particular account(s) before any information is released or action is taken. In certain instances, the requested act or function may result in cost to you, the customer. Requests for information may be limited to the most recent 12 month period. I (Customer) authorize my Agent to act on my behalf to perform the following specific acts and functions (initial all applicable boxes)
The Utility will provide standard customer information without charge up to two times in a 12-month period per service account. After two requests in a year, I understand I may be responsible for charges that may be incurred to process this request.