HonorableRx Prescription Plan Order Form
*This plan is only for Veterans, Senior Citizens, Persons with Disabilities *
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First Name
Last Name
*
Email Address
*
Phone
If this is a gift please type recipient's first and last name
Please type address where bin(s) need to serviced
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Street Address
Street Address
City
State
Zip Code
Please include any gate codes (if applicable)
Are you a Veteran of the Armed Forces?
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Yes
No
If you answered Yes to the above question which Armed Forces did you served?
Air Force
Army
Coast Guard
Marine Corps
Navy
Are you a Young Senior Citizen of age 65 and older?
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Yes
No
Are you a Person with Disabilities?
*
Yes
No
Where did you hear about Doctorbins?
*
TV AD
Flyer
Google
Vehicle Signage
Event
YouTube
Facebook/Instagram
TheOpenHouseShow
Yelp
Friendly Neighbor
If referred by a Friendly Neighbor please type first or last name
Select Trash Collection Day
*
Tuesday
Wednesday
Thursday
Friday
Approximate Trash Collection Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Approximate Recycle Collection Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Bin(s) to be cleaned
Trash Bin Only
Recycle Bin Only
Both Trash and Recycle Bins
Additional Bin(s)
Please select frequency
Once a month
Every other month
Every other week
Every third month
Submit
Should be Empty: