American Midstream (Midla), LLC

Sixth Revised Volume No. 1

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

Original Sheet No. 365 Original Sheet No. 365

TRANSPORTATION SERVICE REQUEST FORM

American Midstream (Midla), LLC

Attention: Contract Administration

1614 15th Street, Suite 300

Denver, CO 80202

Telephone No. (720) 457-6077

Fax No. (720) 457-6040

Re: New Service _ Interruptible Service

or or

Amendment Firm Service

(Contract # _______________)

(Description of existing service to be amended):

__________

Sir or Madam:

(Customer) hereby requests transportation service from

American Midstream (Midla), LLC (Pipeline) and concurrently provides the following

information in connection with this request:

1. Complete legal name of Customer:

________________________________________

2. Duns Number: __________________________Fed Tax

ID:______________________

3. Type of legal entity and State of Incorporation or Formation:

Type of company:

End User LDC

Hinshaw Marketer

Interstate Producer

Intrastate Other (fill in)

___________________________

5. Contact, address and telephone number for Notices:

_____

Contact, address and telephone number for Invoices: