Special Rubbish Pick Up or Additional Recycle Can Form

Special Rubbish Pick Up or Additional Recycle Can Form

City of University Heights
*** WHEN MAKING AN ONLINE PAYMENT, PLEASE USE EITHER A VISA, MASTERCARD, OR DISCOVER CARD. THANK YOU.
Name of Requestor

First NameLast Name
Address of property where pick-up will be performed

Street Address

Street Address Line 2

CityState

Zip Code
Description of what items will be picked up
Phone Number

Area CodePhone Number
Email
example@example.com
Confirmation of $20 or $10 (if 65 years old or older) Fee per Rubbish Pick-up:
Signature

Rubbish Pick-up

Special Rubbish Pick-up Fee

$20.00 Quantity

Rubbish Pick-up (if 65 years old or older)

Special Rubbish Pick-up Fee

$10.00 Quantity

Additional 95 gallon Recycle bin

Special Rubbish Pick-up Fee

$50.00 Quantity

Total

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country