Crossroads Pipeline Company

First Revised Volume No. 1

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Effective Date: 11/01/2001, Docket: RP02- 14-000, Status: Effective

Original Sheet No. 512 Original Sheet No. 512 : Effective

 

REQUEST FOR SERVICE

NEW AGREEMENT

 

1.a. Identity of Requestor

 

Legal Company Name __________________________________________________________________

 

Abbreviation or short name (if applicable)___________________________________________

 

Phone Number _____________________________

 

Facsimile Number _________________________

 

b. Identity of Shipper (if different than Requestor)

 

Written documentation must be submitted to support Requestor's legal authorization to negotiate and/or bind

the Shipper contractually.

 

Legal Company Name _________________________________________________________________

 

Abbreviation or short name (if applicable)___________________________________________

 

Phone Number _____________________________

 

Facsimile Number _________________________

 

 

ADDRESSES FOR NEW AGREEMENT

 

MAILING

Street ______________________________________________________________________________________

 

City _______________________________________________________________________________________

 

State ______________________________________________________________________________________

 

Zip Code ____________________________________________________________________________________

 

Contact Person (Mr., Mrs., Miss, Ms.) _______________________________________________________

 

 

BILLING (if different than Mailing)

Street ______________________________________________________________________________________

 

City _______________________________________________________________________________________

 

State _______________________________________________________________________________________

 

Zip Code ____________________________________________________________________________________

 

Contact Person (Mr., Mrs., Miss, Ms.) _______________________________________________________