Kentucky West Virginia Gas Company

Third Revised Volume No. 1

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Effective Date: 07/01/1993, Docket: RS92- 18-004, Status: Effective

Original Sheet No. 301 Original Sheet No. 301 : Superseded

 

Service Request Form (Continued)

 

(d) Contact Person for Request:_____________________________________

 

Mailing Address:________________________________________________

 

Street Address:_________________________________________________

 

Phone:__________________________________________________________

 

Telecopy No.:___________________________________________________

 

24-hour contact person for purposes of dispatching gas to and

from receipt and delivery points:_______________________________

 

________________________________________________________________

 

Phone:__________________________________________________________

 

Telecopy No.:___________________________________________________

 

1. Is this person an employee of Customer? ____ Yes ____ No

 

2. If no, state relationship to Customer_______________________

 

 

Agreement information:

 

Notices to:___________________ Invoice to:__________________

 

(address)_____________________ (address)____________________

 

______________________________ _____________________________

 

Attn:_________________________ Attn:________________________