Landlord Agreement Application

I request that NATIONAL FUELput gas service in the name listed below whenever a tenant of one of these rental units requests that service be shut off. I understand and agree that:

1. To qualify, any gas bills for which I am responsible must have been paid in full and on time each month;
2. This agreement may be terminated by NATIONAL FUEL if my gas bills are not paid in full and on time each month;
3. Gas service will not be put in my name whenever a tenant’s service is shut off for non-payment;
4. This agreement can only be changed or cancelled in writing; and
5. NATIONAL FUEL must be contacted in writing when selling any of the listed properties.

House Street Unit/ City/ Service Premise/ Business

Number Name Apt # Town Plan/Date Installation# Agreement #

Range Office Use Only Office Use Only

(List additional units on second page)

Service Plans:“A” = ALL YEAR (JANUARY 1 through DECEMBER 31)

“S” = SUMMER (MAY 1 through OCTOBER 31)

“W” = WINTER (NOVEMBER 1 through APRIL 30)

DATE RANGE (Indicate To and From Dates Above)

Account Name

Zip

I HEREBY REQUEST AND APPLY FOR GAS SERVICE TO BE ESTABLISHED IN MY NAME AT THESE ADDRESSES ACCORDING TO THE TERMS AND CONDITIONS OF THIS AGREEMENT AND THE TERMS, CONDITIONS AND RATES CONTAINED IN THE NATIONAL FUEL’S EFFECTIVE GAS TARIFF FILED WITH THE STATE REGULATORY COMMISSION, AND SUBJECT TO ANY MODIFICATIONS OF SUCH TERMS, CONDITIONS AND RATES. BY SIGNING THE APPLICATION, I AGREE TO ACCEPT CUSTOMER ASSISTED READINGS FROM THE TENANTS FOR TRANSFERS OF SERVICE.

READ THE ABOVE STATEMENT BEFORE SIGNING

Signature

Date

Title

Landlord Agreement Application

(Use to list additional units)

House Street Unit/ City/ Service Premise/ Business

Number Name Apt # Town Plan/Date Installation # Agreement #

Range Office Use Only Office Use Only

RETurn original to National Fuel- Retain a copy for your records

4228065 Cons. Bus. (2/18)