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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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