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2. First Name*
3. Last Name*
5. Utility Service Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Email Address
14. Agreement
    For the mutual covenants set forth herein, and for the good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, and intending to be bound herein, the City of North Canton and the Property Owner/account holder, agree as follows:
    
    For my convenience, and although having been advised to be there or have my own representative present, I hereby authorize a representative of the City of North Canton’s Water Department to turn on the water supply to the property described below, without me being present.
    
    For this convenience, I knowingly and expressly agree to release, hold harmless, forever discharge, and indemnify the City, its officers, and employees, from all liability, claim, or cause of action for damage, loss, injury, illness, expense, or property damage, arising or resulting from turning on the water supply without me or my representative being present. This release, waiver, discharge, and indemnification applies to all causes of liability or damage, expense or cost (including attorney fees), loss, injury, illness, or property damage, whether in law or in equity, whether known or unknown, foreseen or unforeseen, including the negligent actions of the City and/or its respective officers, and employees, or which my heirs, executors, administrators, or assigns may have, or claim to have arising out of my decision.
    
    I expressly agree that this waiver shall be governed by and interpreted in accordance with the laws of the State of Ohio. I also agree that in the event any clause or provision in this waiver is found invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this waiver, which shall continue to be enforceable.
    
    Without condition or limitation, I have carefully read the foregoing waiver, understand, and agree with each provision, to be bound by them, and do so as my own free act and will.
16. Electronic Signature Agreement*

    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, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
18. Electronic Signature
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20. 1. Receive an email copy of this form.
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