Intake Form

Market Entry and Compliance Services Information Request

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Account ID

Form Submission Date(Required)

Primary Executive contact

Name(Required)

First Last

Title(Required)

Phone(Required)

Email(Required)

Primary Regulatory Contact

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

Same as Primary Executive Contact

Yes

Name

First Last

Title

Phone

State of Incorporation & Date Incorporated

State(Required)

Date(Required)

EIN(Required)

Regulatory Info

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, acquisition in past 24 months of Company and affiliates.(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.

States & Agencies at Current(Required)

Please provide agencies or indicate ‘None’.

States & Agencies within last 24-months(Required)

Please provide agencies or indicate ‘None’.

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

DBA(Required)

Please provide DBAs or indicate ‘None’.

State(s) Where Used(Required)

Please provide States or indicate ‘None’.

DBA

State(s) Where Used

DBA

State(s) Where Used

DBA

State(s) Where Used

Owners

Name(Required)

First Last

Title(Required)

Phone(Required)

Email(Required)

% of Ownership(Required)

Name

First Last

Title

Phone

% of Ownership

Name

First Last

Title

Phone

% of Ownership

Additional Members, Officers & Directors

Please include all who are listed on related corporate documents.

Name

First Last

Title

Phone

Name

First Last

Title

Phone

Name

First Last

Title

Phone

Name

First Last

Title

Phone

EDI Contact (Please provide all of the following)

Company Name(Required)

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

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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

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Title

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Phone

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Corporate Structure

To the extent applicable, make any changes to ownership structure before applications are submitted; provide corporate chart and note entities that are publicly traded.

File(Required)

Drop files here or

Max. file size: 300 MB.

Customer Service Contact

Name(Required)

First Last

Title(Required)

Phone(Required)

Email(Required)

Customer Service Email Address(Required)

Company Toll-Free Telephone Number(Required)

CAPTCHA

Intake Form

Primary Executive contact

Primary Regulatory Contact

State of Incorporation & Date Incorporated

Regulatory Info

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 within the last 24 months.

Owners

Additional Members, Officers & Directors

EDI Contact (Please provide all of the following)

Bank Information

Corporate Structure

Customer Service Contact

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