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14
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1
Contact Information
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First Name
Last Name
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2
Address
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Tell us where we're going.
Street Address
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City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
What service(s) are you interested in today?
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Select all that apply !
Trash Bin Cleaning
Trash Bin Valet
Pet Waste Cleanup
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4
*
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5
Trash Bin Cleaning
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Please choose between SUBSCRIPTION or ONE TIME CLEANING: Annual Subscription Service – (Our Best Deal!) Bins are cleaned and billed every 8 weeks, with a minimum of 4 cleanings per year required. This discounted rate is offered exclusively to repeat customers. An early cancellation will result in a $35 fee, equivalent to the cost of a one-time cleaning.
Annual Cleaning Subscription - Up to 2 Bin(s) $30 per cleaning
Annual Cleaning Subscription - 3 Bin $50 per cleaning
Monthly Cleaning Subscription - Up to 2 Bin(s) $35 per cleaning
Monthly Cleaning Subscription - 3 Bin $55 per cleaning
One Time Cleaning - 1 Bin $65 per cleaning
One Time Cleaning - 2 Bin $75 per cleaning
One Time Cleaning - 3 Bin $85 per cleaning
Price will be quoted for 4 or more bins
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6
Would you prefer the monthly subscription?
*
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Subscription Service - Bins cleaned & billed every 8 weeks. Minimum of 4 cleanings required within the year. The discount is offered for repeat customers. A $30 fee will be charged for early cancellation (making it the price of 1 time cleaning).
Price will be quoted for 4 or more bins
None
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7
One Time Cleaning (Go back for better deal)
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For ONE TIME CLEANING:
Price will be quoted for 4 or more bins
None
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8
Garbage Pick Up
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Which day of the week is your garbage pick up?
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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9
How often is your recycling collected?
*
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Weekly
Bi-Weekly
Monthly
I am NOT having my recycle bin cleaned
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10
What side of your house are your bins kept?
*
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Right
Left
In driveway
I am NOT having my bin(s) cleaned
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11
What side of your house is your water spigot?
*
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Right
Left
In backyard
I DON'T have a water spigot
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12
Regular subscription is every 8 weeks. Would you prefer your bins to be cleaned more often (if our schedule allows)?
*
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Yes, I'd like cleanings every 4 weeks (once a month)
No, I prefer cleanings every 8 weeks (every other month)
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13
Pet Waste Cleanup
Please choose between SUBSCRIPTION or ONE TIME CLEANING: Subscription Service - Yards cleaned & billed monthly. Minimum of 8 cleanings required within the year. The discount is offered for repeat customers. A $20 fee will be charged for early cancellation (making it the price of 1 time cleaning). (An additional $10 per acre fee will be charged for lots 1 acre or more.)
Pet Waste Cleanup - $20 (A la Carte - One time cleaning)
Pet Waste Cleanup Subscription - Monthly $55 (We clean your yard weekly)
Pet Waste Cleanup Subscription - Annually $50 (We clean your yard weekly)
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14
Valet Trash
Please choose between SUBSCRIPTION or ONE TIME CLEANING: Subscription Service - Bins serviced & billed monthly. Minimum of 8 services required within the year. The discount is offered for repeat customers. A $25 fee will be charged for early cancellation (making it the price of 1 time cleaning).
Valet Trash - $25 (A la Carte - One time cleaning)
Valet Trash Subscription - Monthly $50 (We service your bin weekly)
Valet Trash Subscription - Annually $45 (We service your bin weekly)
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15
How did you hear about The Clean Bin Crew?
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Search Engine
Social Media
Sticker w/ QR Code
Online Ad
Flyer
Other
Other
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16
CC Information
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Nothing will be charged until your serviced is scheduled.
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ORDER SUMMARY
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Credit Card Number
Security Code
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17
Questions, Comments, Gate Code or Special Requests!
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