Authorized User on Existing Account
Status message
Authorized User on Existing Account To whom it may concern, We are sending this form to you, because you have requested to place an authorized user on your account to act on your behalf. Please complete the form below with the required information. Note this must be filled out by the account holder.
Your Full Name
First
Middle
Last
Your Email
Account Number
Status message
I give them permission to do the following for my account located at the following address:
Your Address
Address
Address 2
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
ZIP/Postal Code
I give permission to do the following
Request a delivery
Make contact information changes, such as address, phone number, e-mail address, etc.
Make payment information changes, such as credit card information or banking information
Account cancelation
May be contacted if account should become delinquent for any reason
Status message
Authorized user Information
Authorized User Name
First
Last
Authorized User Phone Number
Authorized User Email
Status message
Authorized User I understand my rights and responsibilities as listed above as an authorized user sent by the account holder listed above for the account listed above. I understand that Mason’s Propane Service LLC will carry out the wishes of the account holder. I understand that the account holder can terminate these rights at any time. I will provide a copy of my driver’s license to keep on the account holders file.
I consent
I have read the above statement and agree to the terms
Signature
Sign above
Name
First
Last
Today's Date
Status message
Account Holder I understand that by signing this form that I, as a consumer, authorize Mason’s Propane Service LLC to update my account with the information I have provided. I understand in order to cancel the authorized users rights it must be by written or electronic notice. Written notices must be mailed to Mason’s Propane Service LLC, P O Box 338, Thomasville, Pa 17364. Mason’s Propane Service LLC as the provider understands that the information provided by the consumer was provided in confidence and will not provide any information to a third party for any advertising purposes, unless written consent is given by the consumer.
I consent
I have read the above statement and agree to the terms
Account Holder Signature
Sign above
Your Name
First
Last
Todays Date