EIA-871B Authorization Form

Authorization Form

2012 Commercial Buildings Energy Consumption Survey

Sponsored by the U.S. Energy Information Administration

U.S. Department of Energy, Washington, DC

This authorization form covers information for each energy source used in the building or establishment identified below, for the period from November 1, 2011 through February 28, 2013.

Name:_______________________________________________

Address: _____________________________________________

City: ________________________________________________

State: _________ ZIP Code: _____________________

Case ID: ______________________________________

Return Mailing Address:

United States Department of Energy

c/o [CONTRACTOR]

STREET.

CITY, STATE ZIPCD-PLUS

Return FAX number: 888-xxx-xxxx

I hereby give permission to the company (companies) below to provide information to [CONTRACTOR] (or other designee of the U.S. Energy Information Administration) for confidential use in connection with the 2012 Commercial Buildings Energy Consumption Survey. A photocopy of this form may be accepted with the same authority as the original.

__________________________________________________ ___________________________________(____)__________

Please print name of authorizing person Employed by Telephone

__________________________________________________ __________________________________________________

Signature of authorizing person Address (if different from above)

__________________________________________________ __________________________________________________

Title City State ZIP

Print full name of energy supplier for each energy source.

__________________________

Energy Source

__________________________

Energy Source

__________________________

Energy Source

__________________________

Energy Source

__________________________

Energy Source

__________________________

Energy Source

Form EIA-871B

OMB No.: 1905-0145 Expires: xx/xx/xxxx