Granite State Gas Transmission, Inc.

Fourth Revised Volume No. 1

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Effective Date: 03/01/2010, Docket: RP10-322-000, Status: Effective

Original Sheet No. 184 Original Sheet No. 184

FORM FOR REQUEST FOR TRANSPORTATION SERVICE

Date: ________________

Granite State Gas Transmission, Inc.

6 Liberty Lane West

Hampton, New Hampshire 03842

Attention: Transportation Services

Re: _______ New Service, or

_______ Modification of Existing Service

___________________________________ ("Shipper") hereby

requests transportation service from Granite State Gas

Transmission, Inc. ("Transporter") and hereby provides the

following information in connection with this request:

(a) Complete legal name of Shipper:

___________________________________________

(b) Type of legal entity and state of incorporation:

___________________________________________

(c) Type of company

_________ Local Distribution Company

_________ Interstate Pipeline

_________ Intrastate Pipeline

_________ Producer

_________ End-User

_________ Marketer

_________ Broker

_________ Other (fill in)