Extension Request Form

City of Dothan ‐ CD102‐34(f)(3) No extension will be granted to a customer who has been extended three times in the preceding 12 months.
I understand that by entering into this agreement, the full delinquent balance must be paid by the extension date. The amount extended in this agreement cannot be granted any additional extension.
Extension requests must be received no later than 4pm on the business day prior to scheduled disconnection date.
I understand that if the account is disconnected for failure to fulfill this agreement, additional fees will apply.
Customer Acknowledgement of Understanding*field type checkbox
Customer Acknowledgement of UnderstandingI understand the extension information listed above and understand requests after 4pm on the business day before scheduled cut off may not be processed.
Name:*field type single line
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Date:*field type date
Address:*field type single line
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Driver's License Number:*field type single line
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Account Number:field type single line
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Email Address*field type email
Telephone Number:*field type single line
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Electronic Signature Agreementfield type richtext
By submission of this form, you agree and acknowledge that 1) the document 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, and 3) you may still be required to provide a traditional signature at a later date.
Customer Signature:*field type signature

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