Natural Gas J#
Electric J #
Acct #
845-452-2700 or 1-800-527-2714
Attn: Call Center
284 South Avenue, Poughkeepsie, NY 12601

Fax: 845-486-5657
Date
Natural Gas Service Request
Customer Name
Contractor/Plumber's Name
New Service Address
Address
City/Town
City/Town
Phone #
Phone #
Nearest Cross Road
Fax #
Subdivision Name Lot #
Pager/Cell #
Single Family Space Heating BTU
Cooking BTU
Multi-Family Water Heating BTU
Clothes Dryer BTU
No. of Units Generator BTU
Other BTU
Commercial Fireplace BTU
Total
 BTU
Service pipe through wall
and ready connection?		 Yes No Is there a gas appliance installed? Yes No
Estimated date service required:
I would like an appointment for a site meeting
Refer to Central Hudson's "Specifications for Gas Installations" for specifications and information on restoration. In some cases there may be a fee for gas service installations.
Does any equipment require a delivery pressure greater then 4" - 7" W.C.?
(This may not be available; if it is there may be a fee)		 Yes No
If yes, what delivery pressure is required?
A copy of the manufacturers specifications will be required along with this request.
Central Hudson to Complete
Billing Order No.
Amount
Bill to: Name
Address
Sketch/Comments