Intake Form - Feller Energy Law

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Account ID

Form Submission Date(Required)

Primary Executive Contact

Name(Required)

First Last

Title(Required)

Work Phone(Required)

Mobile Phone

Email(Required)

Primary Regulatory Contact

The regulatory contact will receive all correspondence from regulatory agencies regarding compliance.

Same as Primary Executive Contact

Yes

Name

First Last

Title

Phone

Customer Service Contact

Name(Required)

First Last

Title(Required)

Phone(Required)

Email(Required)

Customer Service Email Address(Required)

Company Toll-Free Telephone Number(Required)

Email Distribution Groups

Complaints(Required)

Customer Service(Required)

Legal

Marketing

Regulatory(Required)

State of Incorporation & Date Incorporated

State(Required)

Date(Required)

EIN(Required)

End of Fiscal Year

Month

Year

Regulatory Information

Does the company currently utilize consultants on regulatory matters?(Required)

Yes

Name(Required)

First Last

Title(Required)

Please provide a list of other entities active in the energy space in the corporate family that have not been previously disclosed to Feller Law.(Required)

Please provide entities or indicate ‘None’.

History of bankruptcy, dissolution, merger, or acquisition of Company and affiliates in past 24 months.(Required)

Please provide history or indicate ‘None’.

Please list all states and agencies (e.g. PJM, NYISO, FERC, etc.) where the Company is currently licensed, or has been within the last 24 months.

Additional State Agencies

License Number	State	Type	Expiration Date	Commodity	Actions

There are no Licenses.

RTO/ISOs and FERC

ERCOT

FERC Authority

ISO-NE

MISO

NYISO

PJM

None

FERC Authority Docket Number

Copy of License/Approvals

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Max. file size: 300 MB.

Drop files here or Select Files

If applicable, please list trade names (i.e., DBAs) and in what jurisdictions the trade names are used at present or have been used within the last 24 months.

Legal Name(Required)

DBA(Required)

Please provide DBAs or indicate ‘None’.

State(s) Where Used(Required)

Please provide States or indicate ‘None’.

Are there additional Trade Names (DBAs)?

Yes

Additional Trade Names

Legal Name	DBA	State(s) Where Used	Actions

There are no Trade Names (DBAs).

Click ‘Add Trade Name (DBA)’ to add any additional Trade Names.

Ownership

Please provide contact information for any person or entity that holds 10% or more ownership of the Company.

Name(Required)

First Last

Company Legal Name (if applicable)

Title(Required)

Phone(Required)

Email(Required)

% of Ownership(Required)

Relationship Start Date

Are there others with 10% or more ownership?

Yes

Additional Owners

Name	Company Legal Name (if applicable)	Title	Phone	Email	% of Ownership	Relationship Start Date	Actions

There are no Owners.

Click ‘Add Owners’ to add additional owners.

Officers & Directors

Please identify officers and directors.

Name

First Last

Title

Phone

Are there other officers and/or directors to be listed?

Yes

Additional Officers

Name	Title	Phone	Email	Actions

There are no Officers.

Click ‘Add Officers’ to add any additional officers.

EDI Contact

EDI Vendor Name (Required)(Required)

Response required. Please write “None” if applicable.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Direct Contact Name(Required)

First Last

Title(Required)

Phone(Required)

Email(Required)

Fax(Required)

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Bank Information

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Bank Name

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Name

First Last

Hidden

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Account Number

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Routing Number

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Account Name

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Account Type

Hidden

Title

Hidden

Phone

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Corporate Structure

Please attach the current corporate structure chart

File(Required)

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Max. file size: 300 MB.

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Primary Executive Contact

Primary Regulatory Contact

Customer Service Contact

Email Distribution Groups

State of Incorporation & Date Incorporated

Regulatory Information

Please list all states and agencies (e.g. PJM, NYISO, FERC, etc.) where the Company is currently licensed, or has been within the last 24 months.

If applicable, please list trade names (i.e., DBAs) and in what jurisdictions the trade names are used at present or have been used within the last 24 months.

Ownership

Officers & Directors

EDI Contact

Bank Information

Corporate Structure

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