2. 
6. Do you want to opt out of CareFlite?*

   1. Yes
   2. No
8. Utility Account Number*
10. First Name
11. Last Name
13. Address
15. City
16. State
17. Zip

19. The undersigned hereby notifies the City of Crandall Utility that he/she is the authorized account holder of the above account and that he/she exercises the right to opt out of the $1 per month fee for the Caring-Heart Membership. The undersigned acknowledges that the fee will be removed at the conclusion of the next billing cycle. As a result of opting out, I acknowledge that no one in my household will receive the benefits of the Caring-Heart Membership Program which protects families against out-of-pocket costs for CareFlite's air and ground ambulance service.

21. Today's Date*
    Today's Date
23. Signature*

25. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, 3) you may still be required to provide a traditional signature at a later date, and 4) you are the authorized person on this utility account.

27. Authorization*

    1. I agree
    2. I do not agree
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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field