Address where gas is to be furnished:
Full Name (First, MI, Last):
Street Address:
City:
State:
Zip Code:
Telephone:
Email Address :

Date Moving In:

Address to be Billed (IF DIFFERENT):

Full Name (First, MI, Last):
Street Address:
City:
State:
Zip Code:
Telephone:

CHECK ONE OF THE FOLLOWING:

HOME OWNER   TENANT   BUSINESS

If you are a TENANT you must list Landlord's
Address and Phone Number (REQUIRED)
Full Name (First, MI, Last):
Street Address:
City:
State:
Zip Code:
Telephone:

Please list an Emergency Contact:

Full Name (First, MI, Last):
Street Address:
City:
State:
Zip Code:
Telephone:

Before Submitting you must review "Terms and Conditions" Then type your Initials in the the box to show that you have read the terms and conditons.
(Initial Here) (REQUIRED)by initialing this box you are stating that you have read and agree to the "Terms and Conditions" set forth by Piedmont Gas Co.

The Following information is needed for NEW Service Line Installation
Service Line to be installed at Applicants Expense by:

Piedmont Gas Company     OQ Approved Contractor

Type of Dwelling

Single Family Home
Mobile Home
Business
        Space Heat Only
        Process Gas
       (If Process Gas, please describe
       in additional information box below.)
Unattached Buildings (ie. Garage, Shop, Etc.)
Other

 

Gas Equipment to be Used

                                    No. Units & BTU's

Furnace
Water Heater
Range
Dryer
Fireplace
Grill
Lights
Refrigerator
Pool Heater
Other
(List Other in box below.)

 

Use Box Below for any additional information.