<form-template> <fields> <field type="header" subtype="h2" label="Please complete online form to apply for a water meter" class="header"></field> <field type="text" subtype="text" required="true" label="Name:" description="First and Last Name" class="form-control text-input" name="text-1634578740474"></field> <field type="text" subtype="text" required="true" label="Civic Address Moving To:" description="Street Address" class="form-control text-input" name="text-1647818056314"></field> <field type="text" subtype="text" required="true" label="Mailing Address" class="form-control text-input" name="text-1634578744346"></field> <field type="text" subtype="text" required="true" label="City" class="form-control text-input" name="text-1634578745186"></field> <field type="text" subtype="text" required="true" label="Province" class="form-control text-input" name="text-1634578745940"></field> <field type="text" subtype="text" required="true" label="Postal Code" class="form-control text-input" name="text-1634578746770"></field> <field type="text" subtype="text" required="true" label="Phone Number" description="Home or Cellphone " class="form-control text-input" name="text-1634578743570"></field> <field type="text" subtype="text" required="true" label="Email:" class="form-control text-input" name="text-1647818113409"></field> <field type="text" subtype="text" label="Landlord" description="Enter landlord name here, if applicable" class="form-control text-input" name="text-1634578747531" value="Landlord"></field> <field type="date" required="true" label="Date Effective" class="form-control calendar" name="date-1634578773753" value="Date Effective"></field> <field type="radio-group" label="Would you like to receive your utility bills by email?" class="radio-group" name="radio-group-1634578752401"> <option value="Yes" selected="true">Yes</option> <option value="No">No</option> </field> <field type="text" subtype="text" label="Water Meter Deposit" description="Renters must paid a refundable meter deposit. Conditions apply" class="form-control text-input" name="text-1634578761384"></field> <field type="paragraph" subtype="p" label="Rates: 1) 5/8-inch meter $100 2) 3/4-inch meter $150 3) For commercial users, if average utility billing is greater than Number 1 or Number 2 above, then $300 (such as restaurant)" class="paragraph"></field> <field type="text" subtype="text" required="true" label="CONNECTION FEE" description="All service connection moves subject to fee" class="form-control text-input" name="text-1647382457554" value="$10"></field> <field type="paragraph" subtype="p" label="I hereby apply for the installation of a water meter and agree to pay the connection fee, in addition to a deposit, if applicable. If and when the service is permanently disconnected and the water account charged to me has been paid, a refund will be issued. I further agree to pay all water and sewer accounts within 30 days of receipt of same; otherwise, water service may be discontinued without notice. Attention renters: By signing this form you are giving permission to disclose amounts owing to the property owner and/or giving permission for a copy of the utility bill to be sent to the property owner. Property owners will be advised of any delinquent bills." class="paragraph"></field> <field type="text" subtype="text" required="true" label="Signature" class="form-control text-input" name="text-1634579523276" value="Signature"></field> <field type="date" required="true" label="Date Signed" class="form-control calendar" name="date-1634578779056" value="Date Signed"></field> </fields> </form-template> Submit Submitting...
