Dominion Cove Point LNG, LP

Original Volume No. 1

Effective Date: 05/01/2003, Docket: RP03-341-000, Status: Effective

Original Sheet No. 491 Original Sheet No. 491 : Effective

REQUEST FOR SERVICE FORM

(Continued)

2. IDENTITY OF BUYER

A. Legal Name: ______________________________________________________________________

B. Mailing Address:

____________________________________________________________________________

C. Street Address:

(if different from B, no P.O. Boxes)

____________________________________________________________________________

D. Billing Address:

(if different from B)

____________________________________________________________________________

E. Energy Information Administration (EIA) Code (if known) _________________________

F. Contact Person: (Name) _____________________________________________________

(Phone) _____________________________________________________

(Fax No.) _____________________________________________________

G. State of Incorporation/Business Type

(State) _________________________

(Type, e.g. corporation, general partnership) __________________________________

H. Buyer is:

___ 1. Local Distribution Company

___ 2. Intrastate Pipeline Company

___ 3. Interstate Pipeline Company

___ 4. Enduser

___ 5. Producer

___ 6. Marketer

___ 7. Other: _____________________________________________