Gas Application Please fill out the information below to apply for service. If further information is needed, you will be contacted by your district office. Required fields have a *. Service Address Address * City * ---BicknellBrookvilleBrownsvilleCanneltonCarlisleConnersvilleDuggerEdwardsportEvanstonFarmersburgFerdinandFountain CityGuilfordHuntingburgHymeraJasperLaurelLawrenceburgLeopoldLewisLibertyLintonLynnMetamoraMilanMonroe CityOaktownPennvillePetersburgPimentoPortlandRichmondRidgevilleRileySaint AnthonySaratogaShelburnSt AnthonySt MeinradSullivanSunmanTell CityTerre HauteTroyUnion CityVincennesWest HarrisonWheatlandWilliamsburgWinchesterWinslow State * Zip * Mailing Address (If Different) Address City State Zip First Applicant Info First Name Middle Initial Last Name Suffix Mobile Number * Alternate Phone Number Email Address * Driver License Number * Last 4 of SSN * Date of Birth * Employer Name * Employer Phone Number * Years Employed * Employer Address * Employer City * Employer State * Zip * Emergency Contact Name * Emergency Contact Phone Number * Relationship Second Applicant Info First Name Middle Initial Last Name Suffix Mobile Number * Alternate Phone Number Email Address * Driver License Number * Last 4 of SSN * Date of Birth * Employer Name * Employer Phone Number * Years Employed * Employer Address * Employer City * Employer State * Zip * Emergency Contact Name * Emergency Contact Phone Number * Relationship Other Info Doing Business As (DBA) Name In Care of Name Landlord Information Do you own your property or rent? *: ---OwnRent Landlord Information (If Applicable) Landlord Name Landlord Phone Number E-Delivery of Bills * ---YesNo Enroll in Direct Debit * ---YesNo Include Photo or Attachment of ID Include Second Applicant's Photo or Attachment of ID Requested Date for Gas Connection * Best Time of Day for Gas Connection * ---Early MorningLate MorningEarly AfternoonLate Afternoon Δ