Upstate Energy Credit Card Authorization Form-UE 2-21-2025

Upstate Energy Credit Card Authorization Form

To streamline your billing process and ensure secure transactions, we request that you complete our Credit Card Authorization Form. This form allows us to process payments efficiently and safely for your energy services.

Purpose:

The Credit Card Authorization Form grants Upstate Energy permission to charge your credit card for recurring or one-time payments related to your energy services. This includes monthly bills, service fees, or any other charges to your account.

Instructions:

Please fill out all required fields accurately. Once completed, sign and date the form to authorize the payment processing. You can return the form to us via secure online submission.

Card Type

American Express

Mastercard

Visa

Discover

Cardholder Name

Card Number

CVV Code

Card Expiration Date (MM/YY)

Card Billing Address

Phone Number

Authorization Details:

By completing this form, you authorize Upstate Energy to charge your credit card for the agreed-upon amounts for deliveries, labor, installations, repairs, or deposits. This includes authorization for recurring charges or one-time payments. You also acknowledge that this authorization remains in effect until you provide written notice to Upstate Energy of its termination.

Security and Privacy:

Your security is our top priority. The information provided on this form will be handled with the highest level of confidentiality and used solely for the purpose of processing payments. We utilize secure encryption technologies to protect your data during transmission.

Electronic Signature Acknowledgement

I agree and understand that by signing with my Electronic Signature below, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

I agree to the terms & conditions within this contract.

Your Signature

Please select date of signing (today)

Contact Information:

For any questions or assistance, please contact our customer service team at (845) 255-5747 or at info@upstate-energy.com We appreciate your continued trust in Upstate Energy!