Pooling Service Application

* Pooling Service Requested: Daily General Full Requirements Local Production Energy Choice * Application Submitted By: * Title: * Email Address: * Telephone (enter without hyphens): * Date Submitted:

Business Information

* Complete Legal Name of Firm: * Federal Tax ID: DUNS Number: * Mailing Address: * City: * State / Province: * Zip Code / Postal Code: Country (if foreign): * Telephone (enter without hyphens):

Business Structure

* Legal Structure: LLC Corporation Parent Subsidiary Division Partnership Sole Proprietor Complete Name of Parent Company (if applicable):

Home Office Mailing Address: City: State / Province: Zip Code / Postal Code: Country (if foreign):

Officers, Partners or Proprietors

Name: Title: Telephone (enter without hyphens):

Officer, Partner or Proprietor (2)

Name: Title: Telephone (enter without hyphens):

Officer, Partner or Proprietor (3)

Name: Title: Telephone (enter without hyphens):

Other Information

* Type of Business: * Date of Incorporation:

* Name of Primary Business Contact: * Title: * Telephone (enter without hyphens): * Email:

* Name of Person Responsible for Paying Bills: * Title: * Telephone (enter without hyphens): * Email: * Mailing Address: * City: * State / Province: * Zip Code / Postal Code: Country (if foreign):

Trade References (3 Required)

* Company Name: * Contact Name: * Mailing Address: * City: * State / Province: * Zip Code / Postal Code: Country (if foreign): * Telephone (enter without hyphens):

Bank References

* Bank Name: * Mailing Address: * City: * State / Province: * Zip Code / Postal Code: Country (if foreign): * Telephone (enter without hyphens):

Bank Name: Mailing Address: City: State / Province: Zip Code / Postal Code: Country (if foreign): Telephone (enter without hyphens):

History

Previous Name of Business: Previous Owner: Previous Address: City: State / Province: Zip Code / Postal Code: Country (if foreign):

Additional Details

Tell us about your company and how you'd like to work with Dominion East Ohio? Anything else we should know?

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.

* Signature (Please type full name for electronic signature): * Title: * Date:

Signature (Please type full name for electronic signature): Title: Date:

* Required

After pressing the Submit button once, please allow time for processing.

Choose Your State of Service

Choose Your State of Service

Select my State

Business Information

Business Structure

Officers, Partners or Proprietors

Officer, Partner or Proprietor (2)

Officer, Partner or Proprietor (3)

Other Information

Trade References (3 Required)

Bank References

History

Additional Details

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