<form-template> <fields> <field type="text" subtype="text" required="true" label="Contact Name" class="form-control text-input" name="text-1539276596701"></field> <field type="text" subtype="text" required="true" label="Service Address" class="form-control text-input" name="text-1539276667474"></field> <field type="text" subtype="text" required="true" label="Utility Account Number" class="form-control text-input" name="text-1539277542075"></field> <field type="text" subtype="text" required="true" label="Phone Number" class="form-control text-input" name="text-1539277393275"></field> <field type="text" subtype="text" required="true" label="Email Address" class="form-control text-input" name="text-1539276696298"></field> <field type="paragraph" subtype="p" label="THESE TERMS AND CONDITIONS APPLY IN FULL. IF YOU DO NOT WISH TO BE BOUND BY THEM YOU SHOULD NOT SUBSCRIBE TO E-BILLING. PLEASE BE SURE TO READ THEM CAREFULLY BEFORE SIGNING UP. " class="paragraph"></field> <field type="paragraph" subtype="p" label="By using City of Melville e-billing you agree to accept and abide by the terms and conditions set out below: " class="paragraph"></field> <field type="paragraph" subtype="p" label="1. By signing up to the e-billing service you agree to receive an electronic bill in place of your paper bill; however all correspondence and collection of outstanding amounts will continue to be paper based. " class="paragraph"></field> <field type="paragraph" subtype="p" label="2. You must provide a correct and current valid email address to which you would like your bill to be sent. The privacy and accuracy of that email address is your responsibility, and should that email address ever become invalid or should you wish your bill to be sent to a different email account or if your service address changes, it is your responsibility to notify the City of Melville by filling out a new application form. You will remain fully liable for any bills which were sent to your previous email address. It is your responsibility to ensure that your junk mail filters are set to allow mail to be received from utilitybilling@melville.ca." class="paragraph"></field> <field type="paragraph" subtype="p" label="3. The City of Melville reserves the right to refuse the e-billing service to anyone, for any reason, and to modify or discontinue (permanently or temporarily) the e-billing service to you or all recipients at our discretion." class="paragraph"></field> <field type="paragraph" subtype="p" label="4. All bills that are sent to you by email shall be due and payable on the “due date” of each bill. You will remain fully responsible and liable to pay any bills that have been sent to the email address you have specified, regardless of whether or not you access that email account and read the relevant email, are disconnected from your email account, or for any reason (other than error by the City of Melville) fail to read the relevant billing." class="paragraph"></field> <field type="paragraph" subtype="p" label="5. The City of Melville cannot guarantee uninterrupted access to the e-billing service and makes no guarantees as to its operation, availability, functionality, that it will be free of error or disruption or otherwise. " class="paragraph"></field> <field type="paragraph" subtype="p" label="By submitting below you acknowledge that you have read and agree to all the above noted terms and conditions. Once your application is received, we will e-mail the address provided. You will need to reply to our e-mail and confirm your name, address, and account number to complete the registration." class="paragraph"></field> <field type="radio-group" label="Would you like to receive the City of Melville Newsletter?" class="radio-group" name="radio-group-1539276787018"> <option value="Yes" selected="true">Yes</option> <option value="No">No</option> </field> <field type="date" label="Date" class="form-control calendar" name="date-1539277665538"></field> <field type="radio-group" required="true" label="I have read and agree to the Terms and Condition." class="radio-group" name="radio-group-1539282003534"> <option value="Yes" selected="true">Yes</option> <option value="No">No</option> </field> </fields> </form-template> Submit Submitting...
