EIA-871B Authorization Form

CIPSEA Confidentiality Pledge Revision

Authorization Form 2012 871B

CBECS (Voluntary) (OMB 1905-0145)

OMB: 1905-0211

Document [docx]
Download: docx | pdf

Shape1

Authorization Form





Shape2

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.

Shape3


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.


Shape4


__________________________

Energy Source

Shape5


__________________________

Energy Source

Shape6


__________________________

Energy Source

Shape7


__________________________

Energy Source

Shape8


__________________________

Shape9 Energy Source



__________________________

Energy Source


Form EIA-871B

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

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPSL
File Modified0000-00-00
File Created2021-01-22

© 2024 OMB.report | Privacy Policy