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2. First Name*
3. Last Name*
5. Email Address
6. Phone Number*
8. Town of Apex Utility Account Number*
10. Contribution Type - Monthly Contribution*

    Please add the selected amount to my monthly utility bill.

    1. $1
    2. $3
    3. $5
    4. $10
    5. Other
    6. None (I'm choosing to make a 1-time donation)
11. Other Amount
13. Contribution Type - 1-Time Donation*
    Type none if you chose the monthly contribution option.
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15. 1. Receive an email copy of this form.
16. Email address

    This field is not part of the form submission.

17. Submit

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