Form Center

2. Account #

   office use only

3. Route #

   office use only

5. Name of Builder*
7. Service Address*
9. City
10. State
11. Zip Code
13. County:
14. Lot #
15. Subdivision
17. Billing Address:
19. City
20. State
21. Zip Code
23. Ebill Authorization: *

    1. Yes
    2. No
24. Email for Ebill:
26. Contact Name:*
27. Business Phone Number:*
29. Contact Email Address*
30. Phone Number*
32. Onsite Contact Person*
33. Phone Number*
35. Billing Contact Person
36. Phone Number
38. Natural Gas Equipment being installed:*

    1. Heat
    2. Tank Water Heater
    3. Tankless Water Heater
    4. Range
    5. Logs
    6. Grill
    7. Dryer
    8. Pool Heater
    9. Generator
    10. Heat Pump
    11. Other ( Please Indicate)
39. Other
40. Please indicate the number of each type of equipment if more than 1.
42. Approximate Distance from street to meter location (measured in feet)
43. TOTAL BTU LOAD (cubic ft/hr) _________
44. DELIVERY PRESSURE NEEDED:

    1. 7" meter set
    2. 2lb meter set
    3. 5lb meter set
46. The Department of Transportation (DOT), under Title 49 Part 192.381, enacted new standards for residential gas service line installation to include and Excess Flow Valve on each new residence at services operating at pressures over 10 PSI. The objective of the Excess Flow Valve, also known as the EFV, is to reduce gas flow at such times the service line is damaged and the accidental release of natural gas is imminent.
    
    I certify that all of the above information is complete and accurate. I further understand that providing false information may result in denial or termination of natural gas service. I hereby give my permission to examine my past payment history if deemed necessary by Fountain Inn Natural Gas System.
48. Applicant Signature:
49. Date
    Date
51. Rules and Regulations
    Rules and Regulations

    I have read and agree to the R/R

53. Customer Signature:*
54. Date*
    Date
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field