2. E-Bill Authorization
4. First Name
5. Last Name
7. Address
9. City
10. State
11. Zip Code
13. E-mail address where e-bills will be directed:
15. I authorize the Borough of Seaside Heights to send the utility bills selected below to me via e-mail only. I understand that, if I select this option, I will no longer receive paper bills. I must notify the Borough of Seaside Heights in writing (not e-mail) if I choose to discontinue e-bill notification. I assume the responsibility for any and all consequences related to the failure to receive any e-bill.
17. Electric Account Number
    (If you do not want your electric bill sent via e-mail leave this blank)
19. Water/Sewer Account Number
    (If you do not want your water/sewer bill sent via e-mail leave this blank)
21. Name
    By typing your name you are acknowledging that this would be a signature.
22. Date
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field