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2. Date
   Date

   Date
4. Name
6. Address1
8. Address2
10. City
11. State
12. Zip
14. Phone Number
15. Cell Phone Number
17. Fax Number
18. Email Address
20. Where do you want cans and bins to be picked up from? ex: carport, by front door
24. Doctor note, ADA hang tag- required
26. Electronic Signature Agreement

    1. I agree.

    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.
28. Electronic Signature
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

* indicates a required field