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2. Full Name*
4. Service Address*
6. City*
7. State*
8. Zip Code*
10. Email Address*
12. Additional Email Addresses
    Separated by a comma each
14. Billing Format*
    -- Select One --Email OnlyEmail and Printed
16. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) you are requesting to receive paperless billing and will be emailed a copy of your bill to the email address provided above, 2) if requested to use email only, you will no longer receive a mailed paper bill, 3) you may still request a paper copy of your bill by contacting the Finance Department at 386-763-5326, 4) Email Addresses provided to the City are subject to public records requests and may be disclosed on such a request to individuals or businesses.

    1. I agree.
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field