**Please note: this applies to Municipality of Rhineland Utility Customers only.** <form-template> <fields> <field type="header" subtype="h1" label="Contact Information" class="header"></field> <field type="text" subtype="text" required="true" label="Full Name" placeholder="First Name / Last Name" class="form-control text-input" name="text-1759341476001"></field> <field type="text" subtype="text" required="true" label="Civic address" description="Utility Service Address" placeholder="Civic Address / Town / Postal Code" class="form-control text-input" name="text-1759341497758"></field> <field type="text" subtype="text" required="true" label="Phone Number" placeholder="000-000-0000" class="form-control text-input" name="text-1759341564818"></field> <field type="text" subtype="text" required="true" label="Email Address" placeholder="me@email.com" class="form-control text-input" name="text-1759341586579"></field> <field type="header" subtype="h1" label="Account Information" class="header"></field> <field type="text" subtype="text" label="Utility account number (if known)" class="form-control text-input" name="text-1759341760039"></field> <field type="text" subtype="text" label="Property roll number (if known)" class="form-control text-input" name="text-1759341808335"></field> <field type="header" subtype="h1" label="Authorization" class="header"></field> <field type="checkbox" required="true" label="I consent to receive my utility bills by email only. I understand that paper copies will no longer be mailed. " class="checkbox" name="checkbox-1759341843413"></field> <field type="checkbox" required="true" label="I agree that it is my responsibility to notify the Municipality if my email address changes or if I no longer wish to receive bills electronically" class="checkbox" name="checkbox-1759341909052"></field> <field type="text" subtype="text" required="true" label="Signature/typed name" class="form-control text-input" name="text-1759341982312"></field> <field type="date" required="true" label="Date Field" class="form-control calendar" name="date-1759342002907"></field> </fields> </form-template> Submit Submitting...