• 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.

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.