This form is not a binding contract for natural gas service. We will use this information to document community interest in having Dominion Energy bring natural gas to your community, and to keep you informed as we work toward providing natural gas service to Eureka.

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* 1. What's your name?

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* 2. What is your street address?

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* 3. Do you rent or own your property?

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* 4. Are you interested in natural gas service at your home or business?

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* 5. What type of gas service would you be interested in? (please check all that apply)

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* 6. What is your current source of space heat?

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* 7. What is your current source of  water heat?

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* 8. What appliances do you currently have in your home?

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* 9. If you have propane, is the fuel line black pipe or copper pipe?

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* 10. If you have propane, is the fuel line in the front or back of your home?

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* 11. What do you see as the benefits of having natural gas in Eureka?

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* 12. What questions do you have about natural gas service at your home or business?

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