Eastern Shore Natural Gas Company

Second Revised Volume No. 1

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Effective Date: 11/01/1997, Docket: CP96-128-004, Status: Effective

Original Sheet No. 252 Original Sheet No. 252 : Effective

 

EASTERN SHORE NATURAL GAS COMPANY

SERVICE REQUEST FORM

 

1. General information:

 

(a) Any party seeking new service or a change to existing

service from Eastern Shore Natural Gas Company (Seller)

shall complete a Service Request Form pursuant to the

General Terms and Conditions of Seller's FERC Gas Tariff,

First Revised Volume No. 1. Such party shall be known as

the "Requesting Party".

 

(b) Completed Service Request Forms shall be forwarded to:

 

Director of Customer Services

Eastern Shore Natural Gas Company

P.O. Box 1769

Dover, Delaware 19903-1769

 

2. Information to be provided by the Requesting Party:

 

(a) Requesting Party's Identification:

 

Legal Name: __________________________________________

__________________________________________

 

Address: Street: ________________________________

P.O. Box: ________________________________

City: ________________________________

State: ________________________________

Zip Code: ________________________________

 

Type of Legal Entity: ________________________________

State of Incorporation: ________________________________

 

Requesting Party is (Check One):

 

___ Local Distribution Company

___ Marketer

___ Producer

___ Broker

___ Interstate Pipeline

___ Intrastate Pipeline

___ End-User

___ Other, specify: ______________________________

 

(b) Specify the affiliation of Requesting Party with Seller,

if any:

_________________________________________________________

_________________________________________________________