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. 185 Original Sheet No. 185

FORM FOR REQUEST FOR TRANSPORTATION SERVICE

(Continued)

(d) The specific affiliation of the requester with

Transporter, if any:

______________________________________.

(e) Name of Shipper's contact, address and telephone number

through which correspondence for the following should be directed:

Contact for Request: _____________________________

_____________________________

_____________________________

_____________________________

Contact for Notices: _____________________________

_____________________________

_____________________________

_____________________________

Contact for Invoices: _____________________________

_____________________________

_____________________________

_____________________________

(f) Are additional or new facilities required to receive or

deliver gas for the transportation service requested herein?

_______ Yes _______ No

(g) Name and full title of Officer (or General Partner) of

Shipper who will execute written transportation agreement with

Transporter.

____________________________ _________________________

Name Title