Contact Information

* Full Name
	(First Name, Middle Initial, Last Name)

New Service Owner Information

* Owner Name:
* Do you have service now or had service with NYSEG in the past? NoYes
If Yes, please provide one of the following
Account Number
Service Address
* Mailing Address
Street Address 1
Street Address 2
City  State  ZIP  -
Country
Phone Number:	Ext
Additional Phone Number:	Ext

New Service Information

Electrician / Gas Contractor Name
Electrician / Gas Contractor Phone/Cell Phone:	Ext
* Service Address
Street Address 1
Street Address 2
City  State  ZIP  -
Lot# and road name, include development name if appropriate
Nearest Neighbor
* Directions to Marked Location (i.e. staked driveway, red ribbon on maple tree, etc)
Tax Map ID Number

* Type of Service Requested: ElectricNatural GasBoth

Foundation:	NoneStakedExists
Structure:	NoneStakedExists
Septic:	NoneStakedExists
Driveway:	NoneStakedExists

* Type of Customer: ResidentialNon-residentialIndustrialMunicipal

* Type of Service: Temporary ServiceOverheadUnderground

* Is structure beyond 150 feet from existing electric poles? YesNoUnknown

What is the proposed main breaker size? 100 amp200 amp
400 ampOther
Don't Know

Type of electric and/or gas meter: SingleMultiple

Character of Service: 1 phase, 3 wire, 120/240V1 phase, 3 wire Y, 120/208V
3 phase, 4 wire Y, 120/208V3 phase, 4 wire delta, 120/240V
3 phase, 4 wire Y, 277/480V

For all 3-phase service, NYSEG will spot service and/or make arrangements for Current Transformer (CT) metering equipment.(3-phase service not available in all areas)

* Type of Heating: Electric BaseboardElectric Furnace
Electric Thermal StorageNatural Gas
OilHeat Pump
Other

Heating Load  Kilowatts or BTU's

Additional Load (i.e. air conditioning, pool heating)  Kilowatts or BTU's

Total Natural Gas Load (Please provide detail in Remarks section): (heat, water heating, cooking, fireplaces, generators, pool heating, gas lights..........)

  Less than 350,000 BTU'sGreater than 350,000 BTU's

Square footage of the structure:

Remarks: