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.) _______________________________________________________