{"id":499,"date":"2023-12-20T17:24:42","date_gmt":"2023-12-20T17:24:42","guid":{"rendered":"https:\/\/milcrofton.gov\/milcrofton_newsite\/?page_id=499"},"modified":"2023-12-20T17:24:58","modified_gmt":"2023-12-20T17:24:58","slug":"start-water-service","status":"publish","type":"page","link":"https:\/\/milcrofton.gov\/milcrofton_newsite\/start-water-service\/","title":{"rendered":"Start Water Service"},"content":{"rendered":"<div  class='flex_column av-1qahp-fbea974ffbeabfcd1bdda89c9cdb502b av_two_third  avia-builder-el-0  el_before_av_one_third  avia-builder-el-first  first flex_column_div  '     ><section  class='av_textblock_section av-lqe1nbyb-02944f5717e4632ea219b3bcbbfad789 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><h3>Start Water Service<\/h3>\n<\/div><\/section><br \/>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-lqe1mvek-fa86d8d50d6ab63a5dd1081a2b047444\">\n#top .hr.hr-invisible.av-lqe1mvek-fa86d8d50d6ab63a5dd1081a2b047444{\nheight:40px;\n}\n<\/style>\n<div  class='hr av-lqe1mvek-fa86d8d50d6ab63a5dd1081a2b047444 hr-invisible  avia-builder-el-2  el_after_av_textblock  el_before_av_textblock '><span class='hr-inner '><span class=\"hr-inner-style\"><\/span><\/span><\/div><br \/>\n<section  class='av_textblock_section av-lpfwv202-6e0273b49127359fe5f7b122f45791e9 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><style id=\"wpforms-css-vars-287\">\n\t\t\t\t#wpforms-287 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-287\"><form id=\"wpforms-form-287\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"287\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/milcrofton_newsite\/wp-json\/wp\/v2\/pages\/499?wpforms_form_id=287\" data-token=\"b5fd6863ba1249ef0d082f9f5427a880\" data-token-time=\"1781907561\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-287-field_4-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"4\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">This Application Is For<\/legend><ul id=\"wpforms-287-field_4\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-287-field_4_1\" name=\"wpforms[fields][4]\" value=\"Existing Service\" aria-errormessage=\"wpforms-287-field_4_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-287-field_4_1\">Existing Service<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-287-field_4_2\" name=\"wpforms[fields][4]\" value=\"Active Construction\/Builder*\" aria-errormessage=\"wpforms-287-field_4_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-287-field_4_2\">Active Construction\/Builder*<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-287-field_5-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"5\"><div id=\"wpforms-287-field_5\" aria-errormessage=\"wpforms-287-field_5-error\"><p style=\"font-size: 12px; margin-left: 26px;\"><em><sup>*<\/sup>A temporary hydrant must be in place on the property owner\u2019s side of the meter box before the water meter will be set and service started with Milcrofton.<\/em><\/p>&nbsp;<\/div><\/div><div id=\"wpforms-287-field_7-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"7\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-25-25\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_6-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"6\" style=\"display:none;\"><input type=\"text\" id=\"wpforms-287-field_6\" class=\"wpforms-field-large\" name=\"wpforms[fields][6]\" placeholder=\"Development\" aria-errormessage=\"wpforms-287-field_6-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_8-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"8\" style=\"display:none;\"><input type=\"text\" id=\"wpforms-287-field_8\" class=\"wpforms-field-large\" name=\"wpforms[fields][8]\" placeholder=\"Lot #\" aria-errormessage=\"wpforms-287-field_8-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_9-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"9\" style=\"display:none;\"><input type=\"text\" id=\"wpforms-287-field_9\" class=\"wpforms-field-large\" name=\"wpforms[fields][9]\" placeholder=\"Section\" aria-errormessage=\"wpforms-287-field_9-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_10-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"10\" style=\"display:none;\"><input type=\"text\" id=\"wpforms-287-field_10\" class=\"wpforms-field-large\" name=\"wpforms[fields][10]\" placeholder=\"Phase\" aria-errormessage=\"wpforms-287-field_10-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-287-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Customer Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-287-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" placeholder=\"First\" aria-errormessage=\"wpforms-287-field_0-error\" required><label for=\"wpforms-287-field_0\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-287-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" placeholder=\"Last\" aria-errormessage=\"wpforms-287-field_0-last-error\" required><label for=\"wpforms-287-field_0-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-287-field_11-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">Service Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-287-field_11\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][11][address1]\" placeholder=\"Address Line 1\" aria-errormessage=\"wpforms-287-field_11-error\" required><label for=\"wpforms-287-field_11\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-287-field_11-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][11][address2]\" placeholder=\"Address Line 2\" aria-errormessage=\"wpforms-287-field_11-address2-error\" ><label for=\"wpforms-287-field_11-address2\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-287-field_11-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][11][city]\" placeholder=\"City\" aria-errormessage=\"wpforms-287-field_11-city-error\" required><label for=\"wpforms-287-field_11-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-287-field_11-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][11][state]\" aria-errormessage=\"wpforms-287-field_11-state-error\" required><option class=\"placeholder\" value=\"\" selected disabled>State<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-287-field_11-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-287-field_11-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][11][postal]\" placeholder=\"Zip\" aria-errormessage=\"wpforms-287-field_11-postal-error\" required><label for=\"wpforms-287-field_11-postal\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Zip Code<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-287-field_12-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Is your mailing address the same as the service address?<\/legend><ul id=\"wpforms-287-field_12\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-287-field_12_1\" name=\"wpforms[fields][12]\" value=\"Yes\" aria-errormessage=\"wpforms-287-field_12_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-287-field_12_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-287-field_12_2\" name=\"wpforms[fields][12]\" value=\"No\" aria-errormessage=\"wpforms-287-field_12_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-287-field_12_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-287-field_18-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"18\"><div id=\"wpforms-287-field_18\" aria-errormessage=\"wpforms-287-field_18-error\">&nbsp;<\/div><\/div><div id=\"wpforms-287-field_13-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"13\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Mailing Address<\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-287-field_13\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][13][address1]\" placeholder=\"Address Line 1\" aria-errormessage=\"wpforms-287-field_13-error\" ><label for=\"wpforms-287-field_13\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-287-field_13-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][13][address2]\" placeholder=\"Address Line 2\" aria-errormessage=\"wpforms-287-field_13-address2-error\" ><label for=\"wpforms-287-field_13-address2\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-287-field_13-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][13][city]\" placeholder=\"City\" aria-errormessage=\"wpforms-287-field_13-city-error\" ><label for=\"wpforms-287-field_13-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-287-field_13-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][13][state]\" aria-errormessage=\"wpforms-287-field_13-state-error\" ><option class=\"placeholder\" value=\"\" selected disabled>State<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-287-field_13-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-287-field_13-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][13][postal]\" placeholder=\"Zip\" aria-errormessage=\"wpforms-287-field_13-postal-error\" ><label for=\"wpforms-287-field_13-postal\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Zip Code<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-287-field_19-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"19\"><div id=\"wpforms-287-field_19\" aria-errormessage=\"wpforms-287-field_19-error\">&nbsp;<\/div><\/div><div id=\"wpforms-287-field_17-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_17\">Please Select Service Type <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-287-field_17\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][17]\" required=\"required\"><option value=\"Choose One\"  class=\"choice-4 depth-1\"  >Choose One<\/option><option value=\"Domestic Only\"  class=\"choice-1 depth-1\"  >Domestic Only<\/option><option value=\"Domestic and Irrigation\"  class=\"choice-2 depth-1\"  >Domestic and Irrigation<\/option><option value=\"Irrigation Only-Separate Meter\"  class=\"choice-3 depth-1\"  >Irrigation Only-Separate Meter<\/option><\/select><\/div><div id=\"wpforms-287-field_16-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"16\"><div id=\"wpforms-287-field_16\" aria-errormessage=\"wpforms-287-field_16-error\"><p><b>I hereby make application to Milcrofton Utility District for water service as indicated above at my property at the above service address. In consideration for the provision of water service, I agree as follows:<\/b>\r\n<ol><li>The customer agrees to abide by the District\u2019s Rules and Regulations governing water service to its customers which Rules and Regulations are incorporated in this Contract. The District\u2019s Rules and Regulations may be amended from time to time, and all amendments shall become a part of this Contract at the time of their adoption. A temporary hydrant will be in place on the property owner's side of the meter box before the water meter will be set and service started with Milcrofton.<\/li>\r\n<li>The customer agrees to pay the District for water service at the rates set forth in the District\u2019s Schedule of Fees and Charges and to pay all other applicable fees and charges in the District\u2019s Rules and Regulations.<\/li>\r\n<li>Water bills must be paid in accordance with the District\u2019s Rules and Regulations. Presently, water bills must be paid on or before the discount date shown on the bill to obtain the net rate; otherwise, the gross rate shall apply. Failure to receive a bill will not release a customer from his or her payment obligation or extend the discount date. Water bills are payable by mail to the address shown on the bill, in person at the District\u2019s business office or by automatic bank draft. In the event a bill is not paid on or before the tenth (10th) day after the discount date, the customer\u2019s service may be discontinued without further notice. Should a final date for payment of a bill at the net rate fall on a Saturday, Sunday or a holiday, the next business day following the final date will be the last day to obtain the net rate. A net remittance received by mail after the time limit for payment at the net rate will be accepted by the District if the envelope is date-stamped on or before the final date for payment of the net amount.<\/li>\r\n<li>The customer agrees to install and maintain at his or her own expense all water service lines past the District\u2019s meter on his or her property in accordance with the District\u2019s Rules and Regulations.<\/li>\r\n<li>The customer agrees that the District shall not be liable for damages resulting from a failure to supply a sufficient quantity of water or a failure to supply water of any particular quality. The District makes no representation that its water supply will be sufficient for protection against fire damages to the customer\u2019s premises, and the customer agrees that the District shall not be liable for any damages to the customer\u2019s premises resulting from a lack of water for protection.<\/li>\r\n<li>The customer agrees that the District shall not be liable for any damages resulting from high pressure, low pressure or fluctuations in pressure in the District\u2019s water distribution system.<\/li>\r\n<li>After the termination of water service, the customer agrees to pay all outstanding charges and costs under the District\u2019s Rules and Regulations including invoices, costs of repair of the District\u2019s meter or facilities, invoices for statements and late penalties, unpaid fees and charges, interest on all such obligations at the maximum legal rate, and court costs and reasonable attorney fees in the event the District shall employ the service of an attorney to collect such outstanding amounts.<\/li>\r\n<li>If a domestic only customer installs an irrigation system after entering into this Contract for water service, the customer agrees to notify the District that the customer has installed an irrigation system.<\/li><\/ol><\/p>\r\n&nbsp;<\/div><\/div><div id=\"wpforms-287-field_77-container\" class=\"wpforms-field wpforms-field-date-time desireddate\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_77\">Desired Date To Begin Service  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-287-field_77\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-limit-days=\"mon,tue,wed,thu,fri\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][77][date]\" aria-errormessage=\"wpforms-287-field_77-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-287-field_21-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"21\"><div id=\"wpforms-287-field_21\" aria-errormessage=\"wpforms-287-field_21-error\"><p style=\"font-size: 12px; margin-bottom: 25px;\"><em>Please note service will begin the following or future business day.<\/em><\/p>&nbsp;<\/div><\/div><div id=\"wpforms-287-field_22-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"22\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-287-field_3-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_3\">Cell Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-287-field_3\" class=\"wpforms-field-large wpforms-field-required wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][3]\" placeholder=\"Phone\" aria-label=\"Cell Phone\" aria-errormessage=\"wpforms-287-field_3-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-287-field_23-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_23\">Home Phone<\/label><input type=\"tel\" id=\"wpforms-287-field_23\" class=\"wpforms-field-large wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][23]\" placeholder=\"Phone\" aria-label=\"Home Phone\" aria-errormessage=\"wpforms-287-field_23-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-287-field_24-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_24\">Work Phone<\/label><input type=\"tel\" id=\"wpforms-287-field_24\" class=\"wpforms-field-large wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][24]\" placeholder=\"Phone\" aria-label=\"Work Phone\" aria-errormessage=\"wpforms-287-field_24-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-287-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_1\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-287-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" placeholder=\"Email\" spellcheck=\"false\" aria-errormessage=\"wpforms-287-field_1-error\" required><\/div><div id=\"wpforms-287-field_46-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"46\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-25-25\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_62-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_62\">DL # <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-287-field_62\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][62]\" aria-errormessage=\"wpforms-287-field_62-error\" required><\/div><div id=\"wpforms-287-field_52-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_52\">Upload Photo of DL Front <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"52\"\n\t\tdata-form-id=\"287\"\n\t\tdata-input-name=\"wpforms_287_52\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,mp4,txt\"\n\t\tdata-max-size=\"33554432\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"33554432\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-287-field_52\"\n\t\tname=\"wpforms_287_52\" required\t\tvalue=\"\">\n<\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_72-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_72\">State Issued <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-287-field_72\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][72]\" required=\"required\"><option value=\"Select State\"  class=\"choice-4 depth-1\"  >Select State<\/option><option value=\"Alabama\"  class=\"choice-5 depth-1\"  >Alabama<\/option><option value=\"Alaska\"  class=\"choice-6 depth-1\"  >Alaska<\/option><option value=\"Arizona\"  class=\"choice-7 depth-1\"  >Arizona<\/option><option value=\"Arkansas\"  class=\"choice-8 depth-1\"  >Arkansas<\/option><option value=\"California\"  class=\"choice-9 depth-1\"  >California<\/option><option value=\"Colorado\"  class=\"choice-10 depth-1\"  >Colorado<\/option><option value=\"Connecticut\"  class=\"choice-11 depth-1\"  >Connecticut<\/option><option value=\"Delaware\"  class=\"choice-12 depth-1\"  >Delaware<\/option><option value=\"District of Columbia\"  class=\"choice-13 depth-1\"  >District of Columbia<\/option><option value=\"Florida\"  class=\"choice-14 depth-1\"  >Florida<\/option><option value=\"Georgia\"  class=\"choice-15 depth-1\"  >Georgia<\/option><option value=\"Hawaii\"  class=\"choice-16 depth-1\"  >Hawaii<\/option><option value=\"Idaho\"  class=\"choice-17 depth-1\"  >Idaho<\/option><option value=\"Illinois\"  class=\"choice-18 depth-1\"  >Illinois<\/option><option value=\"Indiana\"  class=\"choice-19 depth-1\"  >Indiana<\/option><option value=\"Iowa\"  class=\"choice-20 depth-1\"  >Iowa<\/option><option value=\"Kansas\"  class=\"choice-21 depth-1\"  >Kansas<\/option><option value=\"Kentucky\"  class=\"choice-22 depth-1\"  >Kentucky<\/option><option value=\"Louisiana\"  class=\"choice-23 depth-1\"  >Louisiana<\/option><option value=\"Maine\"  class=\"choice-24 depth-1\"  >Maine<\/option><option value=\"Maryland\"  class=\"choice-25 depth-1\"  >Maryland<\/option><option value=\"Massachusetts\"  class=\"choice-26 depth-1\"  >Massachusetts<\/option><option value=\"Michigan\"  class=\"choice-27 depth-1\"  >Michigan<\/option><option value=\"Minnesota\"  class=\"choice-28 depth-1\"  >Minnesota<\/option><option value=\"Mississippi\"  class=\"choice-29 depth-1\"  >Mississippi<\/option><option value=\"Missouri\"  class=\"choice-30 depth-1\"  >Missouri<\/option><option value=\"Montana\"  class=\"choice-31 depth-1\"  >Montana<\/option><option value=\"Nebraska\"  class=\"choice-32 depth-1\"  >Nebraska<\/option><option value=\"Nevada\"  class=\"choice-33 depth-1\"  >Nevada<\/option><option value=\"New Hampshire\"  class=\"choice-34 depth-1\"  >New Hampshire<\/option><option value=\"New Jersey\"  class=\"choice-35 depth-1\"  >New Jersey<\/option><option value=\"New Mexico\"  class=\"choice-36 depth-1\"  >New Mexico<\/option><option value=\"New York\"  class=\"choice-37 depth-1\"  >New York<\/option><option value=\"North Carolina\"  class=\"choice-38 depth-1\"  >North Carolina<\/option><option value=\"North Dakota\"  class=\"choice-39 depth-1\"  >North Dakota<\/option><option value=\"Ohio\"  class=\"choice-40 depth-1\"  >Ohio<\/option><option value=\"Oklahoma\"  class=\"choice-41 depth-1\"  >Oklahoma<\/option><option value=\"Oregon\"  class=\"choice-42 depth-1\"  >Oregon<\/option><option value=\"Pennsylvania\"  class=\"choice-43 depth-1\"  >Pennsylvania<\/option><option value=\"Rhode Island\"  class=\"choice-44 depth-1\"  >Rhode Island<\/option><option value=\"South Carolina\"  class=\"choice-45 depth-1\"  >South Carolina<\/option><option value=\"South Dakota\"  class=\"choice-46 depth-1\"  >South Dakota<\/option><option value=\"Tennessee\"  class=\"choice-47 depth-1\"  >Tennessee<\/option><option value=\"Texas\"  class=\"choice-48 depth-1\"  >Texas<\/option><option value=\"Utah\"  class=\"choice-49 depth-1\"  >Utah<\/option><option value=\"Vermont\"  class=\"choice-50 depth-1\"  >Vermont<\/option><option value=\"Virginia\"  class=\"choice-51 depth-1\"  >Virginia<\/option><option value=\"Washington\"  class=\"choice-52 depth-1\"  >Washington<\/option><option value=\"West Virginia\"  class=\"choice-53 depth-1\"  >West Virginia<\/option><option value=\"Wisconsin\"  class=\"choice-54 depth-1\"  >Wisconsin<\/option><option value=\"Wyoming\"  class=\"choice-55 depth-1\"  >Wyoming<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_64-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_64\">Exp Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-287-field_64\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][64]\" aria-errormessage=\"wpforms-287-field_64-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_65-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_65\">Fed Tax ID\/Last 4 of SSN<\/label><input type=\"text\" id=\"wpforms-287-field_65\" class=\"wpforms-field-medium\" name=\"wpforms[fields][65]\" aria-errormessage=\"wpforms-287-field_65-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-287-field_75-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"75\"><div id=\"wpforms-287-field_75\" aria-errormessage=\"wpforms-287-field_75-error\">&nbsp;<\/div><\/div><div id=\"wpforms-287-field_31-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"31\"><div id=\"wpforms-287-field_31\" aria-errormessage=\"wpforms-287-field_31-error\"><p style=\"font-size: 12px; margin-top: 15px; margin-bottom: 15px;\">\u201cThe following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race\/national origin or individual applicants on the basis of visual observation or surname.\u201d For more information, see our <a href=\"https:\/\/milcrofton.gov\/milcrofton_newsite\/accessibility\">Accessibility page<\/a>.<\/p>&nbsp;<\/div><\/div><div id=\"wpforms-287-field_32-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"32\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-287-field_34-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_34\">Gender<\/label><select id=\"wpforms-287-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\"><option value=\"Please choose\"  class=\"choice-3 depth-1\"  >Please choose<\/option><option value=\"Male\"  class=\"choice-1 depth-1\"  >Male<\/option><option value=\"Female\"  class=\"choice-2 depth-1\"  >Female<\/option><\/select><\/div><div id=\"wpforms-287-field_37-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">Race (Mark one or more)<\/legend><ul id=\"wpforms-287-field_37\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-287-field_37_1\" name=\"wpforms[fields][37][]\" value=\"White\" aria-errormessage=\"wpforms-287-field_37_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-287-field_37_1\">White<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-287-field_37_2\" name=\"wpforms[fields][37][]\" value=\"Black or African American\" aria-errormessage=\"wpforms-287-field_37_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-287-field_37_2\">Black or African American<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-287-field_37_3\" name=\"wpforms[fields][37][]\" value=\"American Indian\/Alaska Native\" aria-errormessage=\"wpforms-287-field_37_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-287-field_37_3\">American Indian\/Alaska Native<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-287-field_37_5\" name=\"wpforms[fields][37][]\" value=\"Asian\" aria-errormessage=\"wpforms-287-field_37_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-287-field_37_5\">Asian<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-287-field_37_4\" name=\"wpforms[fields][37][]\" value=\"Native Hawaiian\/Other Pacific Islander\" aria-errormessage=\"wpforms-287-field_37_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-287-field_37_4\">Native Hawaiian\/Other Pacific Islander<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-287-field_35-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_35\">Ethnicity<\/label><select id=\"wpforms-287-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\"><option value=\"Hispanic or Latino\"  class=\"choice-1 depth-1\"  >Hispanic or Latino<\/option><option value=\"Non Hispanic or Latino\"  class=\"choice-2 depth-1\"  >Non Hispanic or Latino<\/option><\/select><\/div><\/div><\/div><\/div><div id=\"wpforms-287-field_40-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"40\"><div id=\"wpforms-287-field_40\" aria-errormessage=\"wpforms-287-field_40-error\">&nbsp;<\/div><\/div><div id=\"wpforms-287-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_38\">Employment<\/label><input type=\"text\" id=\"wpforms-287-field_38\" class=\"wpforms-field-large\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-287-field_38-error\" ><\/div><div id=\"wpforms-287-field_59-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"59\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-287-field_60-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_60\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-287-field_60\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][60]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-287-field_60-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-287-field_60-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-287-field_61-container\" class=\"wpforms-field wpforms-field-date-time date-picker\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_61\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-287-field_61\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][61][date]\" aria-errormessage=\"wpforms-287-field_61-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-287-field_41-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"41\"><div id=\"wpforms-287-field_41\" aria-errormessage=\"wpforms-287-field_41-error\"><p style=\"font-size: 16px; padding-top: 40px;\"><b>SPOUSE<\/b><\/p>&nbsp;<\/div><\/div><div id=\"wpforms-287-field_42-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"42\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-287-field_43-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_43\">Cell Phone<\/label><input type=\"tel\" id=\"wpforms-287-field_43\" class=\"wpforms-field-large wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][43]\" placeholder=\"Phone\" aria-label=\"Cell Phone\" aria-errormessage=\"wpforms-287-field_43-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-287-field_44-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_44\">Home Phone<\/label><input type=\"tel\" id=\"wpforms-287-field_44\" class=\"wpforms-field-large wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][44]\" placeholder=\"Phone\" aria-label=\"Home Phone\" aria-errormessage=\"wpforms-287-field_44-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-287-field_45-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_45\">Work Phone<\/label><input type=\"tel\" id=\"wpforms-287-field_45\" class=\"wpforms-field-large wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][45]\" placeholder=\"Phone\" aria-label=\"Work Phone\" aria-errormessage=\"wpforms-287-field_45-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-287-field_66-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"66\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-25-25\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_67-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_67\">DL #<\/label><input type=\"text\" id=\"wpforms-287-field_67\" class=\"wpforms-field-medium\" name=\"wpforms[fields][67]\" aria-errormessage=\"wpforms-287-field_67-error\" ><\/div><div id=\"wpforms-287-field_68-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_68\">Upload Photo of DL Front (copy)<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"68\"\n\t\tdata-form-id=\"287\"\n\t\tdata-input-name=\"wpforms_287_68\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,mp4,txt\"\n\t\tdata-max-size=\"33554432\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"33554432\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-287-field_68\"\n\t\tname=\"wpforms_287_68\" \t\tvalue=\"\">\n<\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_73-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_73\">State Issued<\/label><select id=\"wpforms-287-field_73\" class=\"wpforms-field-medium\" name=\"wpforms[fields][73]\"><option value=\"Select State\"  class=\"choice-4 depth-1\"  >Select State<\/option><option value=\"Alabama\"  class=\"choice-5 depth-1\"  >Alabama<\/option><option value=\"Alaska\"  class=\"choice-6 depth-1\"  >Alaska<\/option><option value=\"Arizona\"  class=\"choice-7 depth-1\"  >Arizona<\/option><option value=\"Arkansas\"  class=\"choice-8 depth-1\"  >Arkansas<\/option><option value=\"California\"  class=\"choice-9 depth-1\"  >California<\/option><option value=\"Colorado\"  class=\"choice-10 depth-1\"  >Colorado<\/option><option value=\"Connecticut\"  class=\"choice-11 depth-1\"  >Connecticut<\/option><option value=\"Delaware\"  class=\"choice-12 depth-1\"  >Delaware<\/option><option value=\"District of Columbia\"  class=\"choice-13 depth-1\"  >District of Columbia<\/option><option value=\"Florida\"  class=\"choice-14 depth-1\"  >Florida<\/option><option value=\"Georgia\"  class=\"choice-15 depth-1\"  >Georgia<\/option><option value=\"Hawaii\"  class=\"choice-16 depth-1\"  >Hawaii<\/option><option value=\"Idaho\"  class=\"choice-17 depth-1\"  >Idaho<\/option><option value=\"Illinois\"  class=\"choice-18 depth-1\"  >Illinois<\/option><option value=\"Indiana\"  class=\"choice-19 depth-1\"  >Indiana<\/option><option value=\"Iowa\"  class=\"choice-20 depth-1\"  >Iowa<\/option><option value=\"Kansas\"  class=\"choice-21 depth-1\"  >Kansas<\/option><option value=\"Kentucky\"  class=\"choice-22 depth-1\"  >Kentucky<\/option><option value=\"Louisiana\"  class=\"choice-23 depth-1\"  >Louisiana<\/option><option value=\"Maine\"  class=\"choice-24 depth-1\"  >Maine<\/option><option value=\"Maryland\"  class=\"choice-25 depth-1\"  >Maryland<\/option><option value=\"Massachusetts\"  class=\"choice-26 depth-1\"  >Massachusetts<\/option><option value=\"Michigan\"  class=\"choice-27 depth-1\"  >Michigan<\/option><option value=\"Minnesota\"  class=\"choice-28 depth-1\"  >Minnesota<\/option><option value=\"Mississippi\"  class=\"choice-29 depth-1\"  >Mississippi<\/option><option value=\"Missouri\"  class=\"choice-30 depth-1\"  >Missouri<\/option><option value=\"Montana\"  class=\"choice-31 depth-1\"  >Montana<\/option><option value=\"Nebraska\"  class=\"choice-32 depth-1\"  >Nebraska<\/option><option value=\"Nevada\"  class=\"choice-33 depth-1\"  >Nevada<\/option><option value=\"New Hampshire\"  class=\"choice-34 depth-1\"  >New Hampshire<\/option><option value=\"New Jersey\"  class=\"choice-35 depth-1\"  >New Jersey<\/option><option value=\"New Mexico\"  class=\"choice-36 depth-1\"  >New Mexico<\/option><option value=\"New York\"  class=\"choice-37 depth-1\"  >New York<\/option><option value=\"North Carolina\"  class=\"choice-38 depth-1\"  >North Carolina<\/option><option value=\"North Dakota\"  class=\"choice-39 depth-1\"  >North Dakota<\/option><option value=\"Ohio\"  class=\"choice-40 depth-1\"  >Ohio<\/option><option value=\"Oklahoma\"  class=\"choice-41 depth-1\"  >Oklahoma<\/option><option value=\"Oregon\"  class=\"choice-42 depth-1\"  >Oregon<\/option><option value=\"Pennsylvania\"  class=\"choice-43 depth-1\"  >Pennsylvania<\/option><option value=\"Rhode Island\"  class=\"choice-44 depth-1\"  >Rhode Island<\/option><option value=\"South Carolina\"  class=\"choice-45 depth-1\"  >South Carolina<\/option><option value=\"South Dakota\"  class=\"choice-46 depth-1\"  >South Dakota<\/option><option value=\"Tennessee\"  class=\"choice-47 depth-1\"  >Tennessee<\/option><option value=\"Texas\"  class=\"choice-48 depth-1\"  >Texas<\/option><option value=\"Utah\"  class=\"choice-49 depth-1\"  >Utah<\/option><option value=\"Vermont\"  class=\"choice-50 depth-1\"  >Vermont<\/option><option value=\"Virginia\"  class=\"choice-51 depth-1\"  >Virginia<\/option><option value=\"Washington\"  class=\"choice-52 depth-1\"  >Washington<\/option><option value=\"West Virginia\"  class=\"choice-53 depth-1\"  >West Virginia<\/option><option value=\"Wisconsin\"  class=\"choice-54 depth-1\"  >Wisconsin<\/option><option value=\"Wyoming\"  class=\"choice-55 depth-1\"  >Wyoming<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_70-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_70\">Exp Date<\/label><input type=\"text\" id=\"wpforms-287-field_70\" class=\"wpforms-field-medium\" name=\"wpforms[fields][70]\" aria-errormessage=\"wpforms-287-field_70-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-287-field_71-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_71\">Fed Tax ID\/Last 4 of SSN<\/label><input type=\"text\" id=\"wpforms-287-field_71\" class=\"wpforms-field-medium\" name=\"wpforms[fields][71]\" aria-errormessage=\"wpforms-287-field_71-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-287-field_76-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"76\"><div id=\"wpforms-287-field_76\" aria-errormessage=\"wpforms-287-field_76-error\">&nbsp;<\/div><\/div><div id=\"wpforms-287-field_54-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_54\">Employment<\/label><input type=\"text\" id=\"wpforms-287-field_54\" class=\"wpforms-field-large\" name=\"wpforms[fields][54]\" aria-errormessage=\"wpforms-287-field_54-error\" ><\/div><div id=\"wpforms-287-field_55-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"55\"><fieldset><legend class=\"wpforms-field-label\">Spouse Name<\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-287-field_55\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][55][first]\" placeholder=\"First\" aria-errormessage=\"wpforms-287-field_55-error\" ><label for=\"wpforms-287-field_55\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-287-field_55-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][55][last]\" placeholder=\"Last\" aria-errormessage=\"wpforms-287-field_55-last-error\" ><label for=\"wpforms-287-field_55-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-287-field_57-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"57\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-287-field_56-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_56\">Spouse Signature<\/label><input type=\"text\" id=\"wpforms-287-field_56\" class=\"wpforms-signature-input wpforms-screen-reader-element\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][56]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-287-field_56-error\" ><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-medium\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-287-field_56-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-287-field_58-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-287-field_58\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-287-field_58\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][58][date]\" aria-errormessage=\"wpforms-287-field_58-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-287-field_78-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"78\"><div id=\"wpforms-287-field_78\" aria-errormessage=\"wpforms-287-field_78-error\"><p style=\"font-size: 16px; padding-top: 40px; padding-bottom: 40px;\">Once you submit this form, you will be redirected to a page where you can make your $100 non-refundable application fee. Enter account number \"onlinemr\".<\/p><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"287\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/milcrofton.gov\/milcrofton_newsite\/wp-json\/wp\/v2\/pages\/499\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-287\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/milcrofton.gov\/milcrofton_newsite\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<\/div><\/section><\/p><\/div><div  class='flex_column av-131u9-b85c53716469d522c12820ee33b5f103 av_one_third  avia-builder-el-4  el_after_av_two_third  avia-builder-el-last  flex_column_div  '     ><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-499","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/milcrofton.gov\/milcrofton_newsite\/wp-json\/wp\/v2\/pages\/499","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/milcrofton.gov\/milcrofton_newsite\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/milcrofton.gov\/milcrofton_newsite\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/milcrofton.gov\/milcrofton_newsite\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/milcrofton.gov\/milcrofton_newsite\/wp-json\/wp\/v2\/comments?post=499"}],"version-history":[{"count":2,"href":"https:\/\/milcrofton.gov\/milcrofton_newsite\/wp-json\/wp\/v2\/pages\/499\/revisions"}],"predecessor-version":[{"id":501,"href":"https:\/\/milcrofton.gov\/milcrofton_newsite\/wp-json\/wp\/v2\/pages\/499\/revisions\/501"}],"wp:attachment":[{"href":"https:\/\/milcrofton.gov\/milcrofton_newsite\/wp-json\/wp\/v2\/media?parent=499"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}