Online Bill Pay Registration Form Name -as it appears on your monthly billing statement * First _ Middle _ * Last Physical Address -where you receive services * Physical Address -where you receive services Physical Address Physical Address City City Zip Zip Is your mailing address the same as your physical address? * Yes No Mailing Address -where you receive your monthly billing statement Mailing Address -where you receive your monthly billing statement Mailing Address Mailing Address City City Zip Zip Email * Required to setup online bill pay. Phone Number * Required to setup online bill pay. Account Number -if known Optional Terms and Conditions Acknowledgement * I hereby acknowledge I am the primary account holder or have been given authority by the primary account holder to submit my/their account information to the City of La Villa in order to setup online bill pay for my water/sewage/trash services. I also acknowledge the information provided above is a true and accurate reflection of the services I currently receive or will receive with the City of La Villa. I also authorize the City of La Villa to use this information to setup online bill pay and consent to receive my monthly water statement to the email address provided with the ability to pay online using a third-party merchant service. I understand I have the right to cancel the online bill pay feature at any time by contacting the City of La Villa City Hall. I further agree to not hold the City of La Villa, its employees, or representatives liable for any damages which may occur by using this online bill pay feature. I further acknowledge the third-party merchant has their own terms and conditions of which I must agree to in order to use this service. Checking this box affirms my agreement to these terms and conditions. Name of person completing this form if not the primary account holder Name of person completing this form if not the primary account holder First First Last Last Signature signature keyboard Clear Captcha Submit If you are human, leave this field blank.