Customer Authorization to Release Information

You may also download the Customer Authorization to Release Information (PDF).

In order for Grays Harbor PUD to release private customer information to a third party, the customer must complete this release in its entirety. The person signing this release must be the customer listed as the current account holder on record in the PUD’s Customer Information System in order to authorize this release.

Customer Name(Required)

First Last

Phone(Required)

Email(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Data to be Released(Required)

(Check all that apply)

Usage or payment history

Balance, due dates

Turn power on or off in my name

Mailing address change

Make payment arrangements

Authorized Accounts(Required)

Click the "+" to add another entry

Account Number

Service Address

Authorized Parties(Required)

Click the "+" to add another entry

Person(s) or Agency Name

Phone Number

This Authorization is in Effect Until(Required)

I provide verbal or written notice of discontinuation of authorization

Specific date range

Effective Dates (mm/dd/yyyy to mm/dd/yyyy)(Required)

Member Electronic Signature (Full Name)(Required)

Phone

This field is for validation purposes and should be left unchanged.