Citizens Business Service Connection Form

* Required Fields

*Name:

*Initial Contact Date:

*Service Address:

Market Type:
IndustrialCommercialSchoolResidential

Customer Name or Company Name:

Structure Type:
ExistingNew Structure

Square Footage of Structure:

Primary Business Function:

Billing Address:

Job Site Contact:

Contact Phone #1:

Contact Phone #2:

Do you have a copy of your Site/Utility plans to provide the Project Coordinator?:
YesNo

*Order Type:

Order Notes:

Additional Details for Change Out Old Meter / Place New and Test Order

Existing Meter #:

Pressure:
6"2#Other Other:

Additional Details for Meter Split Order

For Address #1:

For Address #2:

For Address #3:

For Address #4:

New Meter Location: MarkedStakedStubbed Out

Service Distance – Footage from main to requested meter location:

Equipment Information

Equipment	Total Units	BTU Units	Daily Operation Hours	Existing/New Equipment	Add
				ExistingNew

Future Equipment Information
Is there any load that you intend to add in the Future – if so state below

Equipment	Total Units	BTU Units	Daily Operation Hours	Add

Total Future Load (BTU):

Orders will not be initiated until ALL of the necessary documents and information have been received by the project coordinator. This could include delivery pressure, main extension applications, site utility plans, equipment information, etc. New service orders take up to 4 weeks for completion and main extensions may take up to 6 weeks from the date your order is submitted.