Data Disclosure Agreement

First Name
Last Name

*If you designate a primary telephone number for notifications on your account, you are hereby expressly agreeing that the Cooperative may deliver pre-recorded, artificial voice, and/or auto-dialed messages to this primary telephone number, whether the telephone number is for a landline, wireless, cellular telephone or texts.

City
State
Zip

The undersigned Member of Blue Ridge Electric Membership Corporation hereby requests that Blue Ridge provide to Blue Ridge Energies the confidential data described below, and consents to the disclosures of such data.

If the data is being furnished to a subsidiary of Blue Ridge Electric, the member acknowledges that Blue Ridge Electric has advised that such data will be furnished on a nondiscriminatory basis to any provider of similar services, whether or not such provider is a subsidiary of Blue Ridge Electric, and that Blue Ridge Electric has advised that such products and services may be available from other non-subsidiary suppliers at the member’s request. The Member further acknowledges that if a charge is imposed for such service that the Member will reimburse Blue Ridge Electric promptly upon being billed for Blue Ridge Electric’s reasonable and customary charges incurred in connection with assembling, compiling, and furnishing such data (whether the data is furnished to a subsidiary or non-subsidiary) in accordance with this authorization.

I understand your terms are Net Due-30 days and agree to meet these terms if credit is extended. I agree to pay any and all finance charges, penalties, or court costs resulting from our account being delinquent. A finance charge of 1 ½% per month, which is an annual percentage rate of 18%, will be added to the remaining unpaid balance

Description of data to be provided: Credit Check-New Customer - Blue Ridge Energy