Mississippi Canyon Gas Pipeline, LLC

First Revised Volume No. 1

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Effective Date: 11/01/2009, Docket: RP10-12-000, Status: Pending

Fifth Revised Sheet No. 313 Fifth Revised Sheet No. 313

Superseding: Fourth 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) 214-5791. 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? _________%