American Midstream (Midla), LLC

Sixth Revised Volume No. 1

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Effective Date: 05/01/2010, Docket: RP10-483-000, Status: Effective

Original Sheet No. 363 Original Sheet No. 363

 

EXHIBIT B

INTERACTIVE INTERNET WEBSITE ACCESS REQUEST FORM

 

CUSTOMER (Complete Legal

Name)________________________________________________

 

Mailing Address:

___________________________________________________________

 

City: ____________________________ State: ___________________ Zip:___________

 

DUNS No.: ____________________________ Federal Tax ID No.:

__________________

 

Authorized Employee's Full Name: _________________________________

 

E-Mail Address: __________________________________________________________

 

Authorized Employee's Employer: __________________________________

Mailing

Address:______________________City:________________State:_________Zip:______

_

 

Phone No.: _________________________ Fax No.: ___________________________

 

Authorized Agent?s Full Name: _________________________________

 

E-Mail Address: __________________________________________________________

 

Authorized Agent?s Employer: __________________________________

Mailing

Address:______________________City:________________State:_________Zip:______

_

 

Phone No.: _________________________ Fax No.: ___________________________

 

Indicate Update Capabilities for this Authorized Employee/Agent:

_____ Execute Contracts, Amendments and Accept Discounts

Employee / Agent (circle one)

_____ Make Imbalance Elections/Trades

Employee / Agent (circle one)

_____ Request New Service, Amendments and Discounts

Employee / Agent (circle one)

_____ Receive and administer the payment of any and all invoices

Employee / Agent (circle one)

_____ Submit Capacity Release Offers, Bids, Recall and Reput

Employee / Agent (circle one)