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CUSTOMER DESIGNATION AND AUTHORIZATION OF AGENCY For Company Use Only

Please print or type the information requested below. Submitted Via (circle one)
Hand Delivery/US Mail/Fax/Email

Received On: ___________
By: ____________________

I, ______________________________________________________________________________________________________
Customer Representative Name and Title, (if applicable)

do hereby appoint the following Individual/Company as “Agent” for ________________________________ (“Customer”)
Name of Customer Record

for the Dominion Energy South Carolina, Inc. Accounts (“Designated Accounts) provided below.

Authorized Individual (“Agent”) OR Authorized Company (“Agent”)
Mailing Address
City/State/Zip Code Utility Management Services, Inc.
Telephone No. Company Mailing Address
Facsimile No.
6317 Oleander Dr. Suite C
City/State/Zip Code

Wilmington, NC 28403
Telephone No.

888-867-3230
Facsimile No.

910-793-2946
Primary Contact*
Brian Coughlan
Primary Contact Telephone No.
888-867-3230 x102

Customer may designate a Primary Contact when designating a company as Agent; however, any employees from the
Authorized Company will be authorized to act as Agent on behalf of Customer. The Agent listed above is authorized to act on
Customer’s behalf for the following accounts (use additional sheets for additional accounts).

ACCOUNTS INCLUDED IN THIS AUTHORIZATION
(For More Than Two (2) Accounts, Please Attach Additional Pages)

1. _______________________________________________________________________________________________
Name of Customer (as listed on account)

_______________________________________________________________________________________________

Service Address Dominion Energy Account Number

2. _______________________________________________________________________________________________
Name of Customer (as listed on account)

_______________________________________________________________________________________________

Service Address Dominion Energy Account Number

Customer Designation & Authorization of Agency Page 1 of 3 October 11, 2010
Form Dominion Energy 08-011