Dominion South Pipeline Co., LP

Original Volume No. 1

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Effective Date: 12/16/2005, Docket: CP05- 77-001, Status: Effective

Original Sheet No. 2074 Original Sheet No. 2074 : Effective

 

FORM OF SERVICE AGREEMENT

Access to the Dominion South E-SCRIPT

 

 

ATTACHMENT A

FORM OF AGREEMENT

Access to the Dominion South E-SCRIPT

E-SCRIPT Contact Information Form

(Complete one per Company)

 

Subscriber Information:

 

Provide the following information for each legal entity that you want to name as a

party to the Dominion South E-SCRIPT Agreement.

 

1. Company Name: _______________________ (legal description)

 

2. State of Incorporation: ____________________

(or other legal description, e.g. partnership)

 

3. Company is:

 

__ Local Distribution Company __ Intrastate Pipeline

__ Interstate Pipeline __ Hinshaw Pipeline

__ Marketer __ Broker

__ Producer __ End User

__ Other (please describe ____________________________)

 

4. Affiliated with Dominion South Pipeline Company, LP: __ (Y/N)

 

Address Information:

 

(If the same address is used for multiple parties to the Dominion South E-SCRIPT Agreement,

indicate the address on one form and mark "SAME" on the other forms prepared.)

 

1. Contact and Notification Address (Street Address and Post Office Box.)

 

Name ______________________________________

Title ______________________________________

Address Line 1 ______________________________________

Address Line 2 ______________________________________

City _______________ State ___ Zip ________

Telephone _______________ Facsimile ____________

 

2. Nominations Address (Street Address and Post Office Box.)

 

Name ______________________________________

Title ______________________________________

Address Line 1 ______________________________________

Address Line 2 ______________________________________

City _______________ State ___ Zip ________

Telephone _______________ Facsimile