E-Billing Enrollment Authorization and Agreement
I, the customer identified below, authorize the City of Valparaiso to enroll me in paperless E-Billing which consists of receiving an electronic bill, via email, for monthly cable and/or utility services provided by the City. In addition, I understand E-Billing enrollment authorizes the City of Valparaiso to discontinue mailing paper bills.
Account Name
*
First Name
Middle Initial
Last Name
Business Name (Optional)
Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cable Account No.
*
Non-cable subscribers, enter zero
Utility Account No.
*
Phone Number
*
-
Area Code
Phone Number
E-mail Address
*
Confirmation Email
Confirm the email address of the E-Bill recipient
Comments (Optional)
Enter the letters as displayed
*
Submit
Should be Empty: