Southern LNG Inc.

Original Volume No. 1

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Effective Date: 12/01/2001, Docket: CP99-582-004, Status: Effective

Original Sheet No. 109 Original Sheet No. 109 : Effective

GENERAL TERMS AND CONDITIONS

APPENDIX A

SERVICE REQUEST FORM

Southern LNG

Attention: Customer Services Department

Gentlemen:

_____________________________ (Customer) hereby requests services from Southern LNG Inc. (Southern LNG) and is

providing Southern LNG the following information in connection with this request:

1. Type of service requested is:

_____ new service

_____ new contract to bid on temporary releases of firm capacity

and:

_____ firm service

_____ interruptible service

2. Full legal name of Customer, Dun and Bradstreet number, type of legal entity and, if corporation, state

of incorporation:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Contact person, address and telephone number for Customer in areas of responsibility shown below, a 24-

hour telephone or beeper number, three contact persons for Customer for emergencies and OFOs, and a

facsimile machine number (if available):

General Notices and Correspondence:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________