Authorized User Request

If you would prefer to send a physical copy of this application, you can download the below form and mail to us: Authorized User Request

Customer Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
I authorize Chesapeake Utilities to grant each of the following individuals access to the accounts listed below. I have provided their names and a pass code to be used to verify their Identity. For more than 6 account numbers or authorized users, please see the spreadsheet attached.
Account Numbers
Account Number 1
Account Number 2
Account Number 3
Account Number 4
Account Number 5
Account Number 6
Authorized User List
Name
Pass code
Name 2
Pass code 2
Name 3
Pass code 3
Name 4
Pass code 4
Name 5
Pass code 5
Name 6
Pass code 6
Customer Signature
Title

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