New Service Request Form - Residential
Recycle Depot
Primary Contact Name
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First Name
Last Name
Secondary Contact Name
First Name
Last Name
(Primary Account holder) Date of Birth
*
(Primary Account holder) Name of Employer
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(Primary Account holder) Last 4 of social security
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ALL INVOICES & ALERTS WILL BE SENT VIA EMAIL
Please add adreana@recycledepotfacility.com to your email contact to ensure emails do not go to spam.
Primary Email address
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example@example.com
Secondary Email address
example@example.com
Contact Phone number
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SERVICE Address (Location of garbage pick up)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Requested
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1 Garbage / 1 Recycle
2 Garbage/1 Recycle (addl charge for extra garbage container)
Property Info
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Commercial/Business/Landlord
Personal property(Own and living at)
Renter (living from landlord)
IF RENTING--Landlords name and phone number
We prebill and ask for the first two months up front
We will verbally ask for the full card number for security purposes.
Do you want to be put on auto charge where your payment automatically gets withdrawn from your card? (Authorization form to be signed with details of auto charge will be emailed upon sign up)
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YES AUTO CHARGE
NO AUTO CHARGE (alternate payment options-link for payment, mail check, bank bill pay)
ELIGIBLE FOR DISCOUNT?! ** Proof of ID needed to lock in discount. (Unfortunately, we do not offer a teacher discount at this time) Send copy of ID to adreana@recycledepotfacility.com
Senior - 65 and up
Military/ Veteran
Police / Fireman
ELECTRONIC SIGNATURE: Authorizing Recycle Depot to run your card for start of service and for Auto charge customers to automatically charge your card moving forward. (**For your protection, card will be verbally given to Recycle Depot)
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Please enter full name
Today's Date
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Month
/
Day
Year
Date
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