Authorized User on Existing Account Mason's Propane Authorized User on Existing Account Authorized User on Existing Account To whom it may concern, We are sending this form to you, because you have requested to place an authorized user on your account to act on your behalf. Please complete the form below with the required information. Note this must be filled out by the account holder.Account Holders Name(Required) First Last Account Number(Required)This field will be encryptedYour Email(Required) Service Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I give them permission to do the following for my account located at the above address:I give permission to do the following(Required) Request a delivery Make contact information changes, such as address, phone number, e-mail address, etc. Make payment information changes, such as credit card information or banking information Account cancelation May be contacted if account should become delinquent for any reason Authorized User Name(Required) First Last Authorized User Phone(Required)Authorized User Email(Required) I Consent (Authorized User)(Required) I have read the below statement and agree to the termsAuthorized User I understand my rights and responsibilities as listed above as an authorized user sent by the account holder listed above for the account listed above. I understand that Mason’s Propane Service LLC will carry out the wishes of the account holder. I understand that the account holder can terminate these rights at any time. I will provide a copy of my driver’s license to keep on the account holders file.Authorized User - Name(Required) First Last Date MM slash DD slash YYYY I Consent (account Holder)(Required) I have read the below statement and agree to the termsAccount Holder I understand that by signing this form that I, as a consumer, authorize Mason’s Propane Service LLC to update my account with the information I have provided. I understand in order to cancel the authorized users rights it must be by written or electronic notice. Written notices must be mailed to Mason’s Propane Service LLC, P O Box 338, Thomasville, Pa 17364. Mason’s Propane Service LLC as the provider understands that the information provided by the consumer was provided in confidence and will not provide any information to a third party for any advertising purposes, unless written consent is given by the consumer.Account Holder Name(Required) First Last Date MM slash DD slash YYYY
