Name:
*
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
E-mail Address:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Message:
What day of the week is your garbage pickup?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Cleaning Service Selection
*
Monthly Cleaning: $20/mo for up to 2 cans, $5 per additional can
Quarterly Cleaning: $35 per visit for up to 2 cans, $5 per additional can
One-Time Cleaning: $65 per visit for up to 2 cans, $15 per additional can
Are you military, law enforcement, first responder?
*
Yes
No
Credit / Debit Card Type
*
Please Select
MasterCard
VISA
Discover
AMEX
Cardholder Name (as shown on card)
*
Card Number
*
Expiration Date
*
Credit / Debit Card Billing ZIP Code
*
CVV Code
*
3-digit code on the back of the card for MasterCard, VISA, Discover. 4-digit code on there front of the card for AMEX
Credit/Debit Card Authorization
*
I authorize Rockin Clean Cans to charge my card above for the agreed upon purchase. I understand that my information will be saved to file for future transactions on my account.
Submit
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