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2. First Name*
3. Last Name*
4. Account Number if Known
6. Service Street Address*
7. Copy of Driver's License*

   Copy of Driver's License must be submitted.

11. 96 Gallon Poly Cart (Black Lid)
    

    Poly Cart(s)	Price	Total Cost
    1	$14.85	$14.85
    2	$14.85 + $5	$19.85
    3	$14.85 + $10	$24.85
    4	$14.85 + $15	$29.85

    _{Includes 1 Pickup per Week}

13. Are you requesting your First Poly Cart?

    1. Yes
    2. No
14. 96 Gallon Poly Cart

    1. I need only 1 96-Gallon Poly Cart
    2. I need 2 96-Gallon Poly Carts
    3. I need 3 96-Gallon Poly Carts
    4. I need 4-96 Gallon Poly Carts
15. Additional 96-Gallon Poly Cart(s)

    1. 1 Additional 96-Gallon Poly Cart
    2. 2 Additional 96-Gallon Poly Carts
    3. 3 Additional 96-Gallon Poly Carts
    4. 4 Additional 96-Gallon Poly Carts
19. By Submitting this Form, I Understand and Approve Delivery:*

    1. I have requested the additional poly cart(s) listed to be delivered to the above address. Agree to additional cost.
    2. I am requesting additional poly carts and agree to pay an additional $5.00 per poly cart. Agree to monthly payments.
    3. I understand I will be billed monthly for the additional poly cart(s) requested above.

21. By Electronically Signing Below, You Are Certifying That the Information That You Have Provided Herein Is True and Correct. Agreed and Understood:

23. 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.
25. Electronic Signature
Leave This Blank:


27. Submit

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