Shipper is a(n): (Check one)

_____ Local Distribution Company

_____ Intrastate Pipeline Company

_____ Interstate Pipeline Company

_____ Marketer/Broker

_____ Producer

_____ End-User

_____ Other (please describe _________________________ )

Shipper’s address for statements and invoices:

______________________________________________________

______________________________________________________

______________________________________________________


 

Attention: __________________ Telephone: ( ) ________________


 

For all other matters:

______________________________________________________

______________________________________________________

______________________________________________________


 

Attention: __________________ Telephone: ( ) ________________


 

Acceptance of a service request is contingent upon a satisfactory credit

appraisal by Freebird. Shipper must provide evidence of creditworthiness as

outlined in Section 3.5(g) of the General Terms and Conditions of Freebird’s

currently effective FERC Gas Tariff.


 

By submitting this request, Shipper certifies further that it will execute, if

tendered by Freebird, a Service Agreement for the level of service requested

herein.


 

THIS SERVICE REQUEST IS SUBMITTED THIS _____ DAY OF _______________, _____.

By

Title

Telephone Number ( )

Shipper: (Company Name)