EnviroWaste Registration Form

What works best for you today?

I’m ready to sign up now — fill out the full form including service details & first paymentI’d like someone to contact me — just leave your info and we’ll call you to finish setting things up

Enter your Zip Code*

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Full Name*

First NameLast Name

E-mail*

Phone 1 Type*

Cell Phone is preferred and much needed! We communicate primarily via text. You will miss out on timely announcements if landline or VOIP is provided.

Phone 1*

Service Address*

Location of trash pickup

City*

State*

Zip*

Service?

Service Confirmation

Map

Phone 2 Type

Optional

Phone 2

Optional

Preferred Bill Delivery*

EmailPaperEmail+ Paper

Service start date

Set this to the first day in the week of which you would like service to begin

Service Type*

Residential curbside pickupCommercial dumpster

NOTE: Envirowaste charges a one-time trash can delivery fee of $10

Expected Use for Dumpster (check all that apply)*

NOTE ON DUMPSTERS

NOTE: ENVIROWASTE charges a $125 delivery charge for dumpsters.

As a small company we do not maintain a large inventory of dumpsters on hand. Therefore, dumpsters are not always immediately available.

We appreciate your patience and understanding as we grow our business.

Billing address is*

SameDifferent

Billing Street Address

Billing City

Billing State

Billing Zip

How did you hear about us?*

Select one or more.

Referred By

First NameLast Name

Comments/Detailed Instructions

Help us locate you and your trash can! Let us know where your house number is. House, Mailbox, etc. Dumpsters require DETAILED location info.

Start Service Initial Payment*

Residential Service$85.00

Service Type
Item subtotal:$0.00

2 yard dumpster$270.00

Pickup frequency

4 yard dumpster$340.00

Pickup frequency

Enter coupon

Subtotal $0.00Shipping $0.00Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

The last empty box is for the billing zip code for your payment card

PLEASE NOTE: This form is for NEW customers ONLY!

For existing customers, do NOT attempt to make a payment via this form. Please go to trashbilling.com to pay your bill. Or call us at 330-525-7500

Preferred Ongoing Payment Method

Auto draft ACH from bank accountAuto pay via credit cardCheck or cashOther

I agree to receive occasional text messages regarding my account, route changes or delays, and general communications from Envirowaste Services LLC at the number I provided. Msg & data rates may apply. Reply STOP to no longer receive messages

YesNo