Southside Disposal - ACH Authorization

Name*

First NameLast Name

Date*

Date

Email*

example@example.com

Additional Email

example@example.com

Address for Trash Pick-up Service*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Format: (000) 000-0000.

Monthly Payment for Weekly Trash Pick-up and Disposal Service*

Customer Owned Trash Cans with Curbside/Roadside Pickup

Customer will use their own trash can(s) (up to 2). Customer will roll trash can(s) out to the curb or road every week by 6:30AM on the collection day.

$30

Southside Disposal Trash Can with Curbside/Roadside Pickup

Southside Disposal will provide the customer with a 64 gallon trash can. Customer will roll trash can out to the curb or road every week by 6:30AM on the collection day.

$35

Back Door Pickup (OPTIONAL)

Customer can leave trash can(s) in a convenient place near the home or business and Southside Disposal will pick up bagged trash in that location on the collection day.

$15

Additional Trash Cans (OPTIONAL)

Southside Disposal may provide ADDITIONAL 64 gallon trash cans in addition to the can provided for an extra $10 per month per can. These additional cans must be used by a current customer at the same address.

$10 Quantity

Total

$0.00

Senior Citizen and Military Discount

Monthly (ACH or Credit Card)Quarterly (Cash or Check)Annual (Cash or Check)

Name(s) on Bank Account (business name if used)

Bank Name

Bank Phone Number

Format: (000) 000-0000.

Routing Number

must be 9 numbers - no spaces

Account Number

must be 9-12 numbers - no spaces

Credit Card Information (Credit Card will be charged a 4% Convenience Fee)

Name on Card

Credit Card Number

Expiration DateSecurity Code

Zip Code

Additional Information/Special Instructions

Were you referred by someone?

Signature*

Service Agreement

ACH Payment Information

Credit Card Payment Information