REQUEST FOR SERVICES FORM

Name*

First NameMiddle InitialLast Name

Service Address*

Are you the home owner?*

YesNo

CDIB Number*

#2801A

Phone Number*

Area CodePhone Number

Email*

example@example.com

Are there any ELDERS in the household?*

YesNo

If yes, how many?

Are there any CHILDREN in the household?*

YesNo

If yes, What is their age(s)?

Please Select the Services You Are Requesting.*

Community Clean-up Day AssistanceIllegal Dump ReportSenior AssistanceBulky Waste Pickup Request

Bulky Waste Pickup Request Type (Check all that apply)

Bed Size

TwinQueenKing

If possible please provide a detailed description of your message or need below:

Attestation By accepting this assistance, I hereby grant the Cheyenne and Arapaho Tribes, Environmental Protection Agency (EPA) Program, and its employees, its assigns agents, and subcontractors hereby referred to as "Service Providers" permission to enter upon my property for the collection of said items as described on attached "Request for Services Form." I hereby waive and release the Service Providers from any claims that may arise from said collection. I will not hold the Cheyenne and Arapaho Tribes, the Tribal EPA, and it's Service Providers liable for any damages that may occur including driveways, houses, fences, yards, or vehicles while conducting said collection.

SIGNATURE*

DATE

Date

Cheyenne and Arapaho Tribes Environmental Protection Agency

REQUEST FOR SERVICES FORM