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. 253 Original Sheet No. 253 : Effective

 

EASTERN SHORE NATURAL GAS COMPANY

SERVICE REQUEST FORM

(Continued)

 

(c) If Requesting Party is acting as agent in arranging this

service, specify below each principal (complete legal

name, type of legal entity and state of incorporation)

and its respective type of company. Requesting Party

must supply agency agreements for each principal.

 

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

 

(d) Name and full title of individual who is authorized to

execute a Service Agreement with Seller on behalf of

Requesting Party:

 

Name: _____________________________

Title: _____________________________

 

(e) Contact person for this Request:

 

Name: ________________________

Address: Street: ________________________

P.O. Box: ________________________

City: ________________________

State: ________________________

Zip Code: ________________________

Telephone Number: ________________________

Facsimile Number: ________________________

 

(f) Twenty-four (24) hour contact person(s) for purposes of

scheduling gas:

 

Name: ________________________

Address: Street: ________________________

P.O. Box: ________________________

City: ________________________

State: ________________________

Zip Code: ________________________

Telephone Number: ________________________

Beeper Number: ________________________

Facsimile Number: ________________________