Natural Gas Service Application

Single Family Residential New Construction

Complete the fields below to submit your application for natural gas service.

Note: If installing service in West Virginia and the account is to be opened in the customer's name, please have the homeowner call 877-587-8570 to make the application.

Premise

If the premise type is not listed or if you have questions, please call to make an application.

In Ohio, call 888-619-0786
In West Virginia, call 877-587-8570

Premise Type:*

Single Family
Mobile Home
Conversion

Service Address

Street Address:*

City:*
State:*
Zip Code:*

Alternate Street Name:

Nearest Intersecting Street:*

Driving Directions:* Development Name:

Sub-lot:

County:

Builder Information

Applicant Name

First Name:*
Last Name:*

Mailing Address

Street Address:*

City:*
State:*
Zip Code:*

Phone:*

_{(999) 999-9999}

Contact Name

First Name:*
Last Name:*

Email Address:*

Tax ID:*

Approved Dominion Customer Number:

Premise Information

Corner Lot?: Yes No Setback:*

Gas Equipment to be Installed

Enter quality of each or "S" for Stub.

Furnace:
Fireplace:
Water Heater:

Gas Logs:
Range/Oven:
Garage Heater:

Dryer:
Gas Light:
Grill:

Other:

* Required

Ready For Tie-In & Meter?

To avoid a redtag fee for a service which cannot be tied, please make sure your plumber has tested the service line before you call.
Fax your completed Service Installation Record and Houseline Installation Record to 1-866-757-6099 when you are ready for the tie & meter.

NOTE: THERE WILL BE A PROCESSING DELAY IF APPLICATION HAS NOT BEEN MADE FIRST!

REMINDER: PLEASE MAKE APPLICATION WHEN YOU PULL YOUR BUILDING PERMIT!

Natural Gas Service Application

Single Family Residential New Construction

Premise

Service Address

Builder Information

Applicant Name

Mailing Address

Contact Name

Premise Information

Gas Equipment to be Installed

Ready For Tie-In & Meter?

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