Mississippi Canyon Gas Pipeline, LLC
First Revised Volume No. 1
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Effective Date: 09/07/2006, Docket: RP06-468-000, Status: Effective
Fourth Revised Sheet No. 313 Fourth Revised Sheet No. 313 : Effective
Superseding: Third Revised Sheet No. 313
SERVICE REQUEST FORM
Requests for service under Mississippi Canyon's FERC Gas Tariff
shall be deemed valid only after the following information is
provided by Shipper in writing to Mississippi Canyon's
Transportation Services, at 1100 Louisiana, Suite 3300, Houston,
Texas 77002, or Fax Number (832) 214-5716. Acceptance of a
request is contingent upon a satisfactory credit appraisal by
Mississippi Canyon in accordance with Section 31 of the General
Terms and Conditions of its FERC Gas Tariff.
Date of Request: _____________________________
I. Shipper (Full Legal Name):
___________________________________________
Shipper Address:
____________________________________________________
____________________________________________________
Telephone No.:
____________________________________________________
Fax No.:
____________________________________________________
E-mail address:
____________________________________________________
Contact Name/Department:
_____________________________________________
II. Type of legal entity and state of incorporation/formation:
_______________________________________________
_______________________________________________
III. Type of company:
_____ Interstate Transporter
_____ Local Distribution Company
_____ Intrastate Transporter
_____ Producer
_____ End-User
_____ Marketer
_____ Broker
_____ Other (describe)_____________________________________
Shipper's Federal Tax ID # ____________________
Shipper's DUNS # ____________________
Is Shipper affiliated with Mississippi Canyon Gas Pipeline,
LLC?
_____ Y _____N
If yes, what is the percentage of affiliation? _________%
Is Shipper's supplier affiliated with Mississippi Canyon
Gas Pipeline, LLC?
_____ Y _____N
If yes, what is the percentage of affiliation? _________%