Gas App 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 * ---BatesvilleBicknellBrookvilleBrownsvilleCanneltonCarlisleConnersvilleDuggerEdwardsportEvanstonFarmersburgFerdinandFountain CityGrandviewGuilfordHuntingburgHymeraJasperLaurelLawrenceburgLeopoldLewisLibertyLintonLynnMetamoraMilanMonroe CityOaktownPennvillePetersburgPimentoPortlandRichmondRidgevilleRileySaint AnthonySaint MeinradSaratogaShelburnSt 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 (If Applicable) Rent or Own * ---OwnRent Landlord Name Landlord Phone Number Enrollment/Preferences E-Delivery of Bills * ---YesNo Enroll in Direct Debit * ---YesNo Requested Connection Date * Best Time For Connection * ---Early MorningLate MorningEarly AfternoonLate Afternoon Include Photo or Attachment of ID * Include Second Applicant's Photo or Attachment of ID I hereby agree to pay OHIO VALLEY GAS CORPORATION/OHIO VALLEY GAS,INC. as prescribed in its effective rate schedule(s) as they exist from time to time. I understand and will comply with the approved OHIO VALLEY GAS CORPORATION/OHIO VALLEY GAS/INC. General Rules and Regulations Applicable to Gas Service and acknowledge receipt of an OHIO VALLEY GAS pamphlet which describes my rights and responsibilities as a residential gas customer. I furthur acknowledge that a deposit will be required, if I cannot prove that I am credit worthy or do not pay my bills in a timely manner. I hereby certify that the foregoing information is true to the best of my knowledge and belief. The installation of a meter by OHIO VALLEY GAS CORPORATION/OHIO VALLEY GAS, INC. shall constitute a contract for the service applied for.