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<form name="Meter_Order_Request" action="meter-order.html"> <table border=0><tr> <td colspan="2" class="main" align="center"><b><u>Customer Information:</u></b></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">Name:</td> <td class="main">
<input id="txtName" size="30" name="txtName" value="" type="text"> </td> </tr>
<tr> <td class="main" align="right" nowrap="nowrap" valign="top">Service Location:</td> <td class="main">
<textarea id="txtServLoc" name="txtServLoc" cols="25"></textarea></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">Mailing Address:</td> <td class="main">
<textarea id="txtMailAddr" name="txtMailAddr" cols="25"></textarea></td> </tr> <tr>
<td class="main" align="right" nowrap="nowrap">Home Phone:</td> <td class="main">
<input id="txtHomeTel" size="19" name="txtHomeTel" value="" type="text"></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">Work Phone:</td> <td class="main">
<input id="txtWorkTel" size="19" name="txtWorkTel" value="" type="text"></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">Email:</td> <td class="main">
<input id="txtEmail" size="19" name="txtEmail" value="" type="text"></td> </tr> <tr>
<td class="main"> </td> <td class="main"><input id="cbCSR" name="cbCSR" type="checkbox">I would like a CSR to contact me</td> </tr> <tr> <td class="main"> </td> <td class="main"><input id="cbFSA" name="cbFSA" type="checkbox">I would like an FSQA to contact me</td> </tr> <tr> <td class="main"> </td> <td class="main"> </td>
</tr> <tr> <td colspan="2" class="main" align="center"><i>Please note there is an $35.00 fee for meter installation.</i></td> </tr>
<tr> <td class="main"> </td> <td class="main"> </td> </tr> <tr> <td colspan="2" class="main" align="center"><b><u>Location Information:</u></b></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">Street Name:</td>
<td class="main">
<input id="txtStName" name="txtStName" size="24" value="" type="text"></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">House Number:</td>
<td class="main">
<input id="txtStNum" name="txtStNum" size="2" value="" type="text"></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">Town:</td> <td class="main">
<select size="1" id="txtTown" name="txtTown"> <option>Select Town</option> <option value="Addison">Addison</option> <option value="Barnet">Barnet</option> <option value="Barre City">Barre City</option> <option value="Barre Town">Barre Town</option> <option value="Bellows Falls">Bellows Falls</option> <option value="Berlin">Berlin</option> <option value="Bolton">Bolton</option>
<option value="Buels Gore">Buels Gore</option> <option value="Burlington">Burlington</option> <option value="Cabot">Cabot</option> <option value="Calias">Calias</option> <option value="Charlotte">Charlotte</option> <option value="Colchester">Colchester</option> <option value="Corinth">Corinth</option> <option value="Danville">Danville</option> <option value="Dover">Dover</option>
<option value="Dummerston">Dummerston</option> <option value="Duxbury">Duxbury</option> <option value="E Montpelier">E Montpelier</option> <option value="Essex">Essex</option> <option value="Fayston">Fayston</option> <option value="Ferrisburg">Ferrisburg</option> <option value="Groton">Groton</option> <option value="Hartford">Hartford</option> <option value="Hartland">Hartland</option>
<option value="Hinesburg">Hinesburg</option> <option value="Huntington">Huntington</option> <option value="Jericho">Jericho</option> <option value="Jonesville">Jonesville</option> <option value="Marshfield">Marshfield</option> <option value="Middlesex">Middlesex</option> <option value="Monkton">Monkton</option> <option value="Montpelier">Montpelier</option> <option value="Moretown">Moretown</option>
<option value="Newbury">Newbury</option> <option value="New Haven">New Haven</option> <option value="Northfield">Northfield</option> <option value="Norwich">Norwich</option> <option value="Orange">Orange</option> <option value="Panton">Panton</option> <option value="Peacham">Peacham</option> <option value="Planfield">Planfield</option> <option value="Putney">Putney</option>
<option value="Richmond">Richmond</option> <option value="Rockingham">Rockingham</option> <option value="Ryegate">Ryegate</option> <option value="Searsburg">Searsburg</option> <option value="Shelburne">Shelburne</option> <option value="South Burlington">South Burlington</option> <option value="Stamford">Stamford</option> <option value="Starksboro">Starksboro</option> <option value="Stowe">Stowe</option>
<option value="Thetford">Thetford</option> <option value="Topsham">Topsham</option> <option value="Vergennes">Vergennes</option> <option value="Vernon">Vernon</option> <option value="Waitsfield">Waitsfield</option> <option value="Waltham">Waltham</option> <option value="Warren">Warren</option> <option value="Washington">Washington</option> <option value="Waterbury">Waterbury</option>
<option value="Waterford">Waterford</option> <option value="Westminister">Westminister</option> <option value="Williamstown">Williamstown</option> <option value="Williston">Williston</option> <option value="Wilmington">Wilmington</option> <option value="Winooski">Winooski</option> <option value="Worcester">Worcester</option></select></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">This meter will be next<br> to meter number:</td>
<td class="main">
<input id="txtMtr" name="txtMtr" size="24" value="" type="text"></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">This meter will be fed from<br> transformer number:</td> <td class="main">
<input id="txtXfmr" name="txtXfmr" size="24" value="" type="text"></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">Rate:</td>
<td class="main">
<input id="txtRate" size="10" name="txtRate" value="" type="text"></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">Residential:</td> <td class="main"><input id="cbResRate" name="cbResRate" type="checkbox"></td> </tr> <tr> <td class="main" align="right" nowrap="nowrap">Commercial:</td> <td class="main"><input id="cbComRate" name="cbComRate" type="checkbox"></td> </tr> <tr> <td class="main"> </td>
<td class="main"> </td>
</tr> <tr> <td colspan="2" class="main" align="center"><b><u>Other Information:</u></b></td> </tr> <tr> <td class="main"> </td> <td class="main"><input id="cbNewCon" name="cbNewCon" type="checkbox">I need a new Construction order</td> </tr> <tr> <td class="main" align="right" nowrap="nowrap" valign="top">Special Instructions:</td> <td class="main"><textarea id="txtSpecInst" name="txtSpecInst" cols="25"></textarea></td>
</tr> <tr>
<td class="main" align="right" nowrap="nowrap">Date/Time Needed:</td> <td class="main"><input id="txtDate" name="txtDate" size="24" value="" type="text"></td> </tr> <tr> <td class="main"> </td> <td class="main"> <input type="hidden" name="Submitted" value="true"> <input id="submit1" value="Submit" name="submit1" type="submit"></td> </tr> </table>
</form>
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