Upstate Utilities & Consultants Inc.
Authorization to Release
Local & Long Distance Data

Referred by
Name (Residential)
Company Name
Contact Phone
Billing Address
State and Zip
Billing Telephone Number(s) including area code and all numbers at those locations.

  • I certify that I am at least 18 years of age, I am the customer or I am authorized by the customer to order service(s) for the number(s) listed on this form.
  • I am authorizing Upstate Utilities to act as my agent to obtain Customer Service Records for all services associated with the numbers listed on this form.
  • I understand that only one local phone company, one regional carrier and one long distance carrier can be designated for each telephone number.
  • This letter of Authorization shall continue for a period of 90 days from the date signed below.
Authorized Name (Please Print):
Sales Name:

You may submit this information and a representative will contact you or you can print this form, sign it and fax it to our office at 518-842-6131.

Daniel Russo

Upstate Utilities & Consultants, Inc.
Daniel Russo • President & Owner
4720 State Highway 30 • Amsterdam, NY 12010
Tel: 518.842.6130 • Fax: 518.842.6131