Eastern Shore Natural Gas Company

Second Revised Volume No. 1

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

Original Sheet No. 254 Original Sheet No. 254 : Effective

EASTERN SHORE NATURAL GAS COMPANY

SERVICE REQUEST FORM

(Continued)

(g) Person to whom invoices and billing notices are to be

directed:

Name: _______________________

Address: Street: _______________________

P.O. Box: ________________________

City: ________________________

State: ________________________

Zip Code: ________________________

Telephone Number: ________________________

Facsimile Number: ________________________

(h) Names and titles of duly authorized individuals

designated to submit nominations to Seller on behalf of

Requesting Party for the requested service:

_____________________________________________________

(i) Identification and location of any facilities to be

constructed or installed by any party affected by the

requested service:

_____________________________________________________

(j) Service is requested under Rate Schedule(s) (Check all

that apply):

___ FT ___ LSS

___ ST ___ LGA

___ IT ___ CFSS

___ GSS