Please indicate the NFGDC Account # (RBA) for the location(s) to which you wish to transport:

YesNo

*required

Customer Name:

Please include complete business name

Person in your organization we should contact regarding Transportation Service issues:

Customer’s Billing Address:

City:

Contact Person’s Mailing Address:

City:

Customer’s Service Address:

City:

Customer’s Corporate (headquarters) Address:

City:

Choose one

CHURCHCORPORATIONGENERAL PARTNERSHIPLlIMITED LIABILITY COMPANYLIMITED PARTNERSHIPMUNICIPAL AUTHORITYMUNICIPALITYNON-PROFIT CORPORATIONNON-PROFIT ORGANIZATIONPARTNERSHIPSCHOOLSCHOOL DISTRICTSOLE PROPRIETORSHIPSTATE/FEDERAL ORGANIZATION

*required

Name of your licensed Gas Supplier/Marketer(s):

In which month do you wish to begin Daily Metered Transportation Service with NFGDC?

End Use(s) of gas at the Service Address shown above:

Select all that apply

APARTMENT BLDG. OR COMPLEXDORMITORYHOSPITALHOTEL OR MOTELJAIL OR PRISONNURSING HOMEOTHER

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