* Name:

* Email:

* Street address:

* Best daytime phone number:

* Our heating system is powered by:

Electricity

Propane

Fuel Oil

* Our water heater is powered by:

Electricity

Propane

Fuel Oil

* If natural gas were available today, we would connect to the service:

Right away

Within 3 months

Within 6 months

Longer

Probably wont

* We would add or change the following appliances to natural gas:

Water Heater

Home Heating

Clothes Dryer

Range

Gas Grill

Fire Logs

Pool/Spa Heater

Gas Lights

Whole House Generator

None