Date Service to Begin (required)

Name of Applicant (required)

Spouse Name

SSN of Applicant

SSN of Spouse

Billing Address (required)

Billing City (required)

Billing State (required)

Billing Zip (required)

Home Phone (required)

Email Address (required)

Service Address (required)

Service City (required)

Service State (required)

Service Zip (required)

Applicant’s Employer (required)

Applicant’s Employer Phone (required)

Spouse’s Employer

Spouse’s Employer Phone (required)

Premises to be used for:
Business UseResidential UseLandlord/Rental

Gas Appliances in Unit:
Check All that Apply
Primary Heat SourceCentral Forced AirGas Log FireplaceHot WaterCookingOutdoor LightingSecondary Heat SourceCentral Boiler SystemSpace HeaterDryerOutdoor GrillHot Tub

Local Contact

Local Contact Phone

Comments and Special Instructions

Enter the code above

I/We hereby apply for gas service by meter, at the address listed above under the published tariff, rules and regulations of Canaan Valley Gas now or hereafter in effect. I/We agree to pay the monthly service fee for such service at the published rates of Canaan Valley Gas as they may appear from time to time, and further agree that this shall be a joint account. For a new service, I/WE AGREE TO PAY AT LEAST THE MINIMUM GAS BILL FOR A PERIOD OF THREE (3) YEARS FROM THE DATE SERVICE IS MADE AVAILABLE TO MY/OUR PROPERTY, REGARDLESS OF WHETHER I/WE ACTUALLY USE SUCH SERVICE. I/We certify that the above information is true and accurate. By submitting this form electronically, I/We acknowledge and affirm that it shall have the same force and effect as if the form were signed by Me/Us.