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2. Are you*

   1. A new commercial customer wanting trash service.
   2. A current commercial customer wanting to make changes to your current trash service.
4. Account Name*
5. Contact Person *
6. Contact Person*
8. Phone Number*
9. Mailing Address*
11. City*
12. State*
13. Zip Code*

15. Delivery Location

17. Date to Start or Change Current Service*
    Date to Start or Change Current Service
18. Delivery Address*
19. Zip Code*
21. Phone Number for Delivery*
22. Type of Work Performed*
23. Are Interested In*
    -- Select One --2, 3, 4, 6, or 8 yard dumpster?20, 30, 40 yard roll-off dumpster?a 96 gallon poly cart or adding additional?
27. Dumpster Size

    1. 2 Yard
    2. 3 Yard
    3. 4 Yard
    4. 6 Yard
    5. 8 Yard
28. How Many Weeks?

    1. 1 Week = $97.35
    2. 2 Weeks = $164.74
    3. 3 Weeks = $213.81
    4. 4 Weeks = $251.92
    5. 5 Weeks = $312.34

    ^{2 Yard Dumpster Size}

29. How Many Weeks?

    1. 1 Week = $115.69
    2. 2 Weeks = $192.27
    3. 3 Weeks = $252.50
    4. 4 Weeks = $321.20
    5. 5 Weeks = $427.62

    ^{3 Yard Dumpster Size}

30. How Many Weeks?

    1. 1 Week = $136.43
    2. 2 Weeks = $241.73
    3. 3 Weeks = $331.49
    4. 4 Weeks = $428.26
    5. 5 Weeks = $472.35

    ^{4 Yard Dumpster Size}

32. How Many Weeks

    1. 1 Week = $175.12
    2. 2 Weeks = $293.97
    3. 3 Weeks = $411.66
    4. 4 Weeks = $597.04
    5. 5 Weeks = $645.02

    ^{6 Yard Dumpster Size}

33. How Many Weeks?

    1. 1 Week = $213.81
    2. 2 Weeks = $370.18
    3. 3 Weeks = $527.73
    4. 4 Weeks = $684.14
    5. 5 Weeks = $858.84

    ^{8 Yard Dumpster Size}

34. Additional Options:

    1. Locks = $26.65 per month
    2. Casters = $26.65 per month
35. Extra Lifts?

    1. 2 Yard, Add $59.90
    2. 3 Yard, Add $65.89
    3. 4 Yard, Add $71.88
    4. 6 Yard, Add $77.87
    5. 8 Yard, Add $83.86
39. Roll-off Dumpster Size

    1. 20 Yard
    2. 30 Yard
    3. 40 Yard
40. Do you know how many days you will be renting the roll-off dumpster?
    -- Select One --YesNo

    Rent Fee $6.95 per day

41. Roll-off Dumpster

    Enter No. of Days Renting

43. 20 Yard Roll Off Dumpster

    1. Non Compactable = $632.98
    2. Compactable Not Available
44. 30 Yard Roll Off Dumpster

    1. Non-Compactable = $872.74 per haul
    2. Compactable = $944.19 per haul
45. 40 Yard Roll Off Dumpster

    1. Non-Compactable = $1112.52 per haul
    2. Compactable = $1133.03.00 per haul
46. Additional Fees

    1. Relocation Fee equal to $79.36 per month
    2. Dry Run Fee equal $189.68 per month
50. How are fees calculated for 96 Gallon Poly Carts?

    First 96 Gallon Cart = $42.07/per month
    Additional Poly Carts = $21.04 each/per month

51. 96 Gallon Poly Cart	Monthly Cost
    1	$42.07
    2	$42.07 + $21.04
    3	$42.07 + $21.04(2)
    4	$37.65 + $21.04(3)

    
    

53. Do you currently have a commercial 96 gallon poly cart?

    1. Yes
    2. No
54. How many additional Poly Carts do you need?

    1. 1
    2. 2
    3. 3
    4. 4+
55. How Many Poly Carts Do You Need?

    1. 1
    2. 2
    3. 3
    4. 4+
57. 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.
59. Electronic Signature
60. Today's Date*
    Today's Date
62. Consent for storing submitted data*

    1. Yes, I give permission to store and process my data.
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64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

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