2. Date of Request*
   Date of Request
   It will take up to 10 days to receive your additional can.
3. Last 4 Digits of Account Holder's Social Security Number*
4. Additional Fees*

   1. I agree to the additional monthly charges and understand that I must keep the additional bin for a MINIMUM of 12 months.

   I understand that there will be an additional fee EACH month accessed to my bill in the amount of $6.33 for each additional bin requested.

6. Account Holders First Name*
   Only Account Holders are allowed to make a request of additional cans.
7. Account Holder's Last Name*
9. Account Street Address*
   Physical Street Address of Account
10. Utility Account Number*

    Please include all 13 digits of account number along with dashes

12. Number of additional TRASH cans requested
    -- Select One --012
13. Number of additional RECYCLE Cans requested
    -- Select One --012
15. Email Address*
16. Phone Number*
18. Terms & Agreements *

    Only Legal Account Holders are authorized to submit any request for additional bins which add additional charges. By submitting this request you are confirming that you are the Legal Account Holder.

    1. I confirm that I am the Legal Account Holder and Authorize the additional fees to be added to my account.
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field