National Grid - Gas Service

Gas Service This form is used for:

New gas service (for contractors or someone who is building their home)
Conversion or relocation of gas service

For help completing this form, please review Gas Service Additional Information or our Steps for Gas Service.

	( = required information)

General Information
Order Type:
Is this for residential or commercial service?

Customer Information
Customer Name:
Telephone:	()-
Email Address:	Note: Contractors do not need to fill in the customer email address.
Customer/Business Name (for billing):
Does this customer (or business) currently or previously have service with us?
	*If Yes, please provide the account number, and continue at the Contractor Information section below.
	Account Number:
	**If No, please complete the rest of this section.
Customer/Business Mailing Address:
Address 2:
City:
State:	Zip Code:
Employer:
Social Security No. or Taxpayer Id:
Spouse's Name:
Type of Business:

Contractor Information
Contractor Name:
Address:
City:
State:	Zip Code:
Contact Name:
Telephone:	()-
Fax Number:	()-
Email Address:

Building/Structure Information
Date Service Requested:	/ / (8 weeks lead time required.)
Service Address:	Lot Number (if applicable)
Address 2:
City:
State:	Zip Code:
Service Phone:	()-
Lot/Loc Staked?
Date Foundation Completed:	/ /
Is the structure framed or completed?
	*If no, date when to be framed or delivered.
	/ /
Point of attachment:

Gas Service Information
Number of Gas Meters:
	* If more than one meter, indicate the instructions for designating the meters (i.e., 1 house meter and 6 apartment meters labeled Apt 1 - Apt 6)

Total Proposed Load: (CFH or BTU?)

Appliances/units to be connected: Hold down <Ctrl> key to make multiple selections	Other (Specify):
Service to install:

Life Sustaining Equipment Will there be any of the following electrically-operated life-sustaining medical devices in use at this address?
Apnea Monitor:
Home Kidney Dialysis Machine:
Continuous Ventilation Device:
Suction (Aspiration) Machine:
Other:

Directions to Property
Closest Intersection:
Development Name:

Additional Comments
Comments: