Laserfiche WebLink
AMEREN ENERGY FUELS AND SERVICES <br /> GAS TRANSPORT CUSTOMER,AGENT/BROKER AUTHORIZATION FORM <br /> (This form is required) <br /> By signing below the undersigned Customer agrees to the following terms: <br /> 1. The agent/broker listed below is authorized to make nominations with Ameren <br /> Energy Fuels and Services on behalf of Customer for the account(s) listed below <br /> with AmerenCILCO,AmerenClPS,AmerenlP,or AmerenUE. <br /> 2. The agent/broker will be given access to all information that Ameren Energy Fuels <br /> and Services may provide from time to time on the USMS — Gas Transportation <br /> System regarding Customer's account(s). <br /> 3. The agent/broker has a relationship (contractual or otherwise)with Customer and is <br /> not necessarily a business party of AmerenCILCO, AmerenClPS, AmerenlP, <br /> AmerenUE or Ameren Energy Fuels and Services. Ameren Energy Fuels and <br /> Services, AmerenCILCO, AmerenClPS, AmerenlP, and AmerenUE's obligations are <br /> to their customers and not their customer's brokers. <br /> 4. Customer shall notify, in writing, Ameren Energy Fuels and Services in the event j <br /> Customer terminates an existing relationship with the agent/broker. <br /> Please list below the agent(broker that you are giving authorization. <br /> Agent/broker's Company Name: Integrys Energy Services <br /> Address: 500 W. Madison St,Citicorp Center,33rd F1,Chicago, IL 60661 <br /> Contact Name: Joel Ruetten <br /> Phone Number: (920 )±17- 6421 <br /> I authorize this broker to include me in a pool group: es No (Circle One) <br /> I authorize this broker to make bank transfers: Yes No (Circle One) <br /> THIS SECTION ONLY APPLIES TO ILLINOIS CUSTOMERS <br /> A RG12 form must be submitted to Ameren if this agent/broker will be collecting gas <br /> revenue tax for your account(s). If no form is received, Ameren will apply Gas Use Tax <br /> to your account(s). If you are exempt from Gas Use Tax, a RG61 is required. Please <br /> send the completed RG12 or RG61 form to Bob Cecil, Ameren Corporation, P.O. Box <br /> 66149, St. Louis, MO 63103, <br /> Customer Signature: Date: <br /> Title: <br /> Company: <br /> Account Number(s): <br /> Fax to: Mike Garrett: (217) 535-5006 <br /> or Mail to: Ameren Energy Fuels and Services <br /> Attn: Mike Garrett <br /> 607 East Adams Street <br /> Springfield, IL 62739 <br />