Transferring Service Form

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

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:

Date Moving In:

Please list an Emergency Contact:

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

To Schedule your final reading at your current location you must fill out the
Terminating Service Form.

 

Date Moving In:

 

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.

IF RENTING WE REQUIRE A SECURITY DEPOSIT - WE WILL CONTACT YOU BY PHONE OR MAIL TO LET YO KNOW THE AMOUNT OF THE DEPOSIT.

ALL NEW CUSTOMERS ARE REQUIRED TO FILL OUT APPLICATION - APPLICATION FOR GAS SERVICE IS LOCATED ON OUR APPLICATIONS PAGE UNDER TRANSFERRING SERVICE FORM, BY SUBMITTING APPLICATION YOU AGREE TO BE RESPONSIBLE FOR THE PAYMENT OF ALL NATURAL GAS USAGE AT THE SPECIFIED SERVICE ADDRESS.

Use Box Below for any additional information.