Order Gas

To request gas, please feel out the form below. DO NOT USE THIS FORM if you have emergencies or questions regarding a Gas Odor or Carbon Monoxide. Instead, please call us immediately at 1-270-547-2455 or 1-270-877-2661.

Delivery Address

   
First Name
Last Name
Social Security Number
Date of Birth
Street Address
City
State   Zip
Phone Number
Alt. Phone
Email Address
   

Billing Address

   
   
Street Address
City
State   Zip

Employment    
Employer
Employer Phone
Years Employed
Position
Street Address
City
State   Zip

Spouse or Co-responsible Adult    
First Name
Last Name
Social Security Number
Date of Birth
Employer
Employer Phone
Years Employed
Position
Street Address
City
State   Zip

Do you own or Rent Property?
 
Landlord's Name
Landlord's Phone

References      
Nearest Relative
Relationship
Street Address
City
State   Zip

Check all Gas Appliances    
Fireplace Cook Stove Water Heater
Space Heater Furnace Dryer
Pool Grill Outlet Generator

Financial      
Bank Institution
   
List three Businesses in which you have an account with:
1.
   
2.
   
3.
   

I understand that by submitting this form, I am applying for New Residential Service. I also understand that submitting this application is as legally binding as signing and submitting a normal paper application with my signature.

Customer Services

Irvington Gas is Kentucky's leader in Propane and Natural Gas products and services. We offer propane service to Breckenridge, Meade, Hardin, Grayson, Larue, and Nelson County in KY. For gas safety and products from Lennox ...

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