EIA-871B Authorization Form

Authorization Form
Commercial Buildings Energy Consumption Survey
Sponsored by the U.S. Energy Information Administration
Conducted by NORC
This authorization form covers the following information for each energy source used in the building or establishment identified
below, for the period from December 1, 2006 through January 31, 2008: 1) the amount used, and 2) the amount billed.

Return Mailing Address:
Commercial Buildings Energy Consumption Survey
c/o NORC
55 East Monroe
Chicago, IL 60603-xxxx

Name:_______________________________________________
Address: _____________________________________________
City: ________________________________________________
State: _________

Return FAX number: 888-xxx-xxxx

ZIP Code: _____________________

Case ID: ______________________________________
I hereby give permission to the company (companies) below to provide information to NORC (or other designee of the U.S. Energy
Information Administration) for confidential use in connection with their survey for the U.S. Energy Information Administration. 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