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Original Sheet No. 304 Original Sheet No. 304 : Superseded

Service Request Form (continued)

Internal Use Only

1. Date and Time Request received________________________________________

2. Sufficient Data (Y/N)_________________________________________________

If no, date letter sent:______________________________________________

3. Agreement Date:_______________________________________________________

4. Agreement No.:________________________________________________________

5. Nature, if any, of Customer's affiliation with Kentucky West Virginia Gas

Company ______________________________________________________________