New User

Please fill out the form below. Note that the [*] fields are required. All information is kept confidential. Contact information will only be used in the event that we need to contact you regarding your account. After completing this form, you will have the opportunity to register for online billing services.

First Name

Last Name*

Name

Note:

If you are registering as an individual, enter your first and last name. If you are registering as a business, enter the business name as last name and leave first name blank.

Address Line 1*

Address Line 2/Suite

City/State/Zip Code*

Phone Number*

example: (209) 555-1212 or (209) 555-1212 3333

Cell Phone Number

example: (209) 555-1212 or (209) 555-1212 3333

Email Address*

Select a Username*

Note: Usernames must be unique in our system, you will receive an error message if the username you have entered already exists in our database.

Your password must be between 4 and 16 characters long and consist of letters and numbers only.

Select a Password*

Repeat Password*