Assignment 7 Form

C & C Account Application & Service Request Form

Note: Required fields are marked with an asterisk (*)

Client Information

Username * user name is required, you may use your email address.

Email Address

All information is strictly guarded and will not be made available to others.

First Name *

Last Name *

Contact Information

Address 1 * street address must be placed in Address 1

Address 2

Select Your City

Errors could be highlighted by giving an error class to the input field, as seen here.

Telephone - -

(###) - ### - ####

Application Date

Month

Day

Year

Account Classification

Client Type *

Client Status * Approved Pending Applications Active Service

Preferred Location Option 1 Option 2 Option 3

Something Else *

Some Option 1
Some Option 2
Some Option 3
Some Option 4

Service or Other Information

Description of Current Problem*

Any Additional Information That May Lower Your Bill

General Nature of Problem: To select more than one Menu Item hold the ctrl key while selecting list Items from the Menu

C and C Plumbing Phone: (805) 481-7550 or email