DOMINION CONFIDENTIAL
REQUEST FOR CERTAIN CREDIT
SOUTH PIPELINE COMPANY, LP AND
FINANCIAL INFORMATION
FULL NAME
OF FIRM (APPLICANT)
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TELEPHONE
(Area Code) |
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MAILING
ADDRESS |
CITY |
STATE/ZIP |
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HOME
OFFICE ADDRESS |
CITY |
STATE/ZIP |
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LEGAL STRUCTURE |
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FULL
NAME OF PARENT COMPANY
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PARENT
COMPANY’S HOME OFFICE
ADDRESS |
CITY
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STATE/ZIP
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OFFICERS, PARTNERS OR PROPRIETOR
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1) |
NAME
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TITLE
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ADDRESS
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PHONE
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2) |
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3) |
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4) |
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5) |
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6) |
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OTHER INFORMATION
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TYPE OF
BUSINESS |
STATE OF INCORPORATION
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DATE OF INCORPORATION
OR DATE
BUSINESS STARTED
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NAME OF
PERSON RESPONSIBLE
FOR PAYING BILLS |
TITLE |
TELEPHONE
NO. ( ) |
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PREVIOUS
NATURAL GAS SUPPLIER AND/OR
TRANSPORTER |
STREET/CITY |
STATE/ZIP |
TEL.
NO. |
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BUSINESS
NAME UNDER WHICH THESE
SERVICES WERE OBTAINED |
STREET/CITY |
STATE/ZIP |
TEL.
NO. |
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TRADE REFERENCES
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1) |
COMPANY |
STREET/CITY |
STATE/ZIP |
TEL.
NO. |
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2) |
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3) |
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4) |
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BANK REFERENCES
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1) |
BANK NAME
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STREET/CITY
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STATE/ZIP
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ACCOUNT OFFICER
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TEL.
NO. |
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2) |
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HISTORY
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PREVIOUS NAME OF BUSINESS
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PREVIOUS OWNER
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PREVIOUS ADDRESS
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PLEASE SUPPLY MOST RECENT FINANCIAL
STATEMENTS
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IT IS HEREBY WARRANTED THAT THE ATTACHED FINANCIAL
STATEMENTS ARE A TRUE REPRESENTATION OF APPLICANT’S FINANCIAL SITUATION. APPLICANT’S SIGNATURE ATTESTS FINANCIAL RESPONSIBILITY AND
WILLINGNESS AND ABILITY TO REMIT AMOUNTS DUE IN ACCORDANCE WITH TERMS OF ANY
APPLICABLE AGREEMENTS BETWEEN DOMINION SOUTH PIPELINE, LP AND/OR WITH TERMS
OF ANY INVOICES RENDERED TO APPLICANT BY DOMINION SOUTH PIPELINE, LP IF
APPLICANT DEFAULTS ON AGREED UPON PAYMENT TERMS. APPLICANT AGREES TO PAY INTEREST PER THE TERMS OF THE CONTRACT
ON THE UNPAID BALANCE IN ADDITION TO COLLECTION COSTS, ATTORNEY FEES AND COURT COSTS SHOULD THEY
BE REQUIRED TO REMEDY THE DEFAULT. THE INFORMATION PROVIDED ON THIS FORM IS FOR THE PURPOSE
OF DETERMINING APPLICANT’S FINANCIAL STABILITY AND IS WARRANTED TO BE
TRUE. WE HEREBY AUTHORIZE DOMINION
SOUTH PIPELINE, LP TO INVESTIGATE THE REFERENCES LISTED HEREIN AND TO EXAMINE
MY/OUR CREDIT HISTORY TO DETERMINE MY/OUR CREDIT AND FINANCIAL RESPONSIBILITY. |
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BY
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____________________________________________________ |
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NAME |
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TITLE |
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___________________________________________________ |
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DATE |
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TEL.
NO. |
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