COMPANY
INFORMATION
|
Please fax
us with the information requested in Part 1 of the following form and
a Kimball representative will contact you. If you would like us to prepare
a free cost comparison for you, please complete Parts 1, 2 and 3 of this
form. Before entering into any transaction, you will also need to provide
a completed Confidential Application for Credit.
To print form, use print function on your browser. To exit form, use the back button or Home Or you can download a form by clicking here and returning it to us by email. |
FAX to 817-274-4724 Attn: Customer Service
| Part 1 - Company Information: | |
| Name: ___________________________________________ |
Phone Number: ________________________ |
| Contact: ___________________________________________ |
E-mail
Address: ________________________ |
| Title: ___________________________________________ |
Fax Number:
________________________ |
| Street
Address: ___________________________________________ |
P.O. Box:
________________________ |
| City: ___________________________________________ |
State: ________________________ |
| Zip: ___________________________________________ |
| Part 2 - Gas Usage Information: | |
| Facility
Name: ___________________________________________ |
City: ________________________ |
| Local Distribution
Co.: ___________________________________________ |
State: ________________________ |
| Interstate
Pipeline(s): _________________________________________________________________________ |
|
Describe your business: _________________________________________________________________________ |
|
Market conditions
that affect your business: _________________________________________________________________________ |
| Total Monthly Usage: | Total Daily Usage: | |
| Highest Usage Month: | Lowest Usage Month: | |
| January ________________ |
Monday ________________ |
Monday ________________ |
| February ________________ |
Tuesday ________________ |
Tuesday ________________ |
|
March |
Wednesday ________________ |
Wednesday ________________ |
| April ________________ |
Thursday ________________ |
Thursday ________________ |
| May ________________ |
Friday ________________ |
Friday ________________ |
| June ________________ |
Saturday ________________ |
Saturday ________________ |
| July ________________ |
Sunday ________________ |
Sunday ________________ |
| August ________________ |
Total ________________ |
Total ________________ |
| September ________________ |
||
| October ________________ |
||
| November ________________ |
||
| December ________________ |
Historical Peak Day: | ________________ |
| Total ________________ |
Total Days
Shut Down Annually: |
________________ |
|
Please
check appropriate space for volume units used
|
| Ccf or Therms__________ | Mcf, Dth or MMBtu__________ |
|
Gas
used for (%)
|
| Space Heat____% | Boiler Heat____% | Process or Feedstock____% |
| Other___% | Describe Other:_______________________________ |
| Alternate fuel, if any:________________________________________________________ |
| Part 3 - Current Supply Information (Optional): | |
| Current
Supplier: ___________________________________________ |
Contract
Expiration Date: ___________________________________________ |
| Delivery
Point : ___________________________________________ |
Firm or
Interruptible? ___________________________________________ |
| Maximum
Daily Take: ___________________________________________ |
Mimimum
Daily Take: ___________________________________________ |
| Demand
Charge: ___________________________________________ |
Commodity
Charge: ___________________________________________ |
| Index Used
(if any): ___________________________________________ |
Transport
Charge: ___________________________________________ |
|
Other
contract terms: ________________________________________________________________________________________ ________________________________________________________________________________________ |
|
Other
comments: ________________________________________________________________________________________ ________________________________________________________________________________________ |
|
Please
FAX to 817-274-4724 Attn: Customer Service
|