10/2009
North Alabama Gas District
P O Drawer 2590 P O Box 1428 P O Box 847
Muscle Shoals, Al 35662 Madison, Al 35758 Town Creek, Al 35672
256-383-3306 Fax 256-386-0627 256-772-0227 Fax 256-772-8098 256-685-2708 Fax 256-685-1888
www.nagd.com
Application for Residential Service
Service Location: _____________________________________________________________
Name of Applicant: ______________________ Place of Employment ___________________
Home Phone: _______________________ Business Phone: ___________________________
Cell Phone: _________________________ Email Address: ___________________________
Mailing Address: _____________________________________________________________
Do You: Own_____ Rent _____ Mortgage Holder/Landlord: __________________________
Landlord’s Address & Phone: ___________________________________________________
Name(s) listed on the Mortgage/Lease ____________________________________________
Driver’s License # & State: __________________ Social Security #: ___________________
Previous Residential Address: ___________________________________________________
Spouse/Roommate information:
Name of Spouse/Roommate: ____________________________________________________
Place of Employment: ________________________ Business Phone: ___________________
Date to start service: _____________________________
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I agree to pay for all material and labor for the installation of the service line at the above address if
no gas us used within 60 days (or by the next cold weather season using heat only) after the natural
gas meter is set. I affirm that the above information is correct.
Signature of Applicant _________________________________________________________
________******** SIGNER IS RESPONSIBLE FOR ALL CHARGES INCURRED *********_______
****Office Use Only****
Date: ___________________ Appliances: Heating Unit ______________
Account #: _______________ Water Heater ______________
Receipt #: ________________ Range ____________________
Deposit #: ________________ Dryer _____________________
Grill ______________________
Dual Fuel Central Unit________
Other ______________________
_PLEASE NOTIFY YOUR GAS COMPANY WHEN ADDING NEW APPLIANCES_
This form must be notarized if paperwork is completed outside North Alabama Gas District’s Office
STATE OF _______________________, COUNTY OF ______________________________
On this ________day of _________________, 20______, personally appeared before me, the above named individual and made
oath that the statements made are true.
______________________________________________________
Notary Public
My Commission Expires: __________________________________
