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Residential Gas Service Request
 
Contractor Request Form
Permanent Residential Gas Service

NOTE: Required fields are indicated With a * below. All required fields must be completed for the request to be processed. If you do not have all of the required information, please obtain it before completing this work request.
Service Type
Today's Date:
Monday June 30, 2025
*Type:
New    Added Load
Added load through existing meter number:
Choose One:
Meter Separation    Meter Combination
Choose One:
Relocate with added load    Relocate without added load
Service Address
*Is the lot in a subdivision?:
Yes    No
*Street Address:
Apt. or Suite:
*City:
*Zip Code:
Subdivision Name:
Lot Number:
Requestor Information
*Your Company:
*Contact Name:
*Contact Phone:
Contact Cell Phone:
Contact Email:
Contact Fax:
Who will pay for this construction? (NOTE: not required in case of DEMOLITION)
*Name:
*Address:
*City, State, Zip:
,    
*Phone:
Email:
Monthly Billing Customer Information (please provide if known)
Name:
Address:
City, State, Zip:
,    
Phone:
Email:
Delivery Pressure (NOTE: not required in case of DEMOLITION)
*Existing (choose one):
1/4 #      2 #      5 #      Line
*Requested (choose one):
1/4 #      2 #      5 #      Line
Existing Load:
(not required)
Mechanical Equipment (Enter information below, if new or added load)
Heating MCF/HR:
Equipment MCF/HR:
Cooking MCF/HR:
Dryer MCF/HR:
Water Heat MCF/HR:
Other (specify):
Special Instructions:
Access Agreement
*You need to send in an Access Agreement for each address. (download by clicking here).
  
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Memphis, TN 38103
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