Business Information

Officers, Partners or Proprietors

Trade References (3 Required)

History

Please include a check in the amount of $50 made payable to Dominion Energy Ohio for the financial evaluation fee.

It is hereby warranted that the attached financial statements are a true representation of applicant's financial situation.

Applicant's signature attests financial responsibility and willingness and ability to remit amounts due in accordance with terms of any applicable agreements between applicant and East Ohio Gas Company (dba Dominion Energy Ohio) and/or with terms of any invoices rendered to applicant by East Ohio Gas Company (dba Dominion Energy Ohio). If applicant defaults on agreed upon payment terms, applicant agrees to pay interest per the terms of the contract on the unpaid balance in addition to collection costs, attorney fees and court costs, should be be required to remedy the default.

The information provided on this form is for the purpose of determining applicant's financial stability and is warranted to be true. I/We hereby authorize East Ohio Gas Company (dba Dominion Energy Ohio) to investigate the references listed herein and to examine my/our credit history to determine my/our credit and financial responsibility.

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