NY AGGREGATION AND CREDIT APPLICATION

Name of Business:

Address:

Billing/Mailing Address:

Contact Person:

YesNo

*required

CorporationLimited Liability CompanySole ProprietorshipSchool or School DistrictChurch or Religious InstitutionNot-for-Profit OrganizationPartnershipLimited PartnershipMunicipal EntityMunicipal AgencyMunicipality

OFFICERS / PRINCIPALS OF BUSINESS APPLICANT

Home Address:

Home Address:

Home Address:

Please check all that are requested

Daily Metered Transportation Aggregation (DMT)

Supplier Transportation, Balancing and Aggregation (STBA)

ADDITIONAL APPLICANT INFORMATION:

YesNo

*required

YesNo

*required

If applicable, when do you wish to initiate services as a Supplier Transportation, Balancing and Aggregator?

If applicable, when do you wish to initiate services as a Daily Metered Transportation Aggregator?

YesNo

*required

BANK REFERENCES:

Address & Branch:

Address & Branch:

ADDITIONAL CREDIT / TRADE REFERENCES:

Address:

Address:

Address:

The undersigned hereby authorizes National Fuel Gas Distribution Corporation to make whatever credit inquiries it deems necessary in order to process this credit application; regarding any credit review or the collection of any debts accrued as a result of any credit extended as a result of their reliance on the information provided on or obtained from credit references given on this application. In addition, the undersigned hereby authorizes and instructs any person or credit reporting agency to compile and furnish National Fuel Gas Distribution Corporation any information it may have or may find necessary to obtain in response to requested credit inquiries. The undersigned further asserts that they have the authority to grant the permission to relinquish the requested information.

Signature

sign after printing

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