Service Agreement
Direct Deposit Authorization (ACH)
Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date
Email
*
example@example.com
Additional Email
example@example.com
Address for Trash Pick-up Service
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Monthly Payment for Weekly Trash Pick-up and Disposal Service
*
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( X )
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
Senior Citizen and Military Discount
Payment Method
*
Monthly (ACH or Credit Card)
Quarterly (Cash or Check)
Annual (Cash or Check)
ACH Payment Information
Use for Monthly Automatic Withdrawal from Bank Account
Name(s) on Bank Account (business name if used)
Type of Bank Account
Personal Checking
Personal Savings
Business Checking
Business Savings
Other
Bank Name
Bank Phone Number
Routing Number
must be 9 numbers - no spaces
Account Number
must be 9-12 numbers - no spaces
Credit Card Payment Information
Use for Monthly Automatic Payment with Credit Card (with 4% Convenience Fee)
Credit Card Information (Credit Card will be charged a 4% Convenience Fee)
Name on Card
Credit Card Number
Expiration Date
Security Code
Zip Code
Additional Information/Special Instructions
Were you referred by someone?
Signature
*
Submit
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