2. REFUSE AND RECYCLING PROGRAM APPLICATION

4. Pickup Location Address*
5. Utility Account #
7. Property Owner Name *
9. Property Owner Address *
11. Property Owner Phone Number*
13. TYPE OF SERVICE (check all that apply):
15. ADDITIONAL REFUSE CART ($33 per quarter)*

    1. Please send me an additional refuse cart.
    2. I am not interested in an additional refuse cart.
17. CURBSIDE RECYCLING PROGRAM ($13.17 per quarter/cart included)*

    1. Please sign me up for the Curbside Recycling Program and send me a recycling cart.
    2. Please send me an additional recycling cart. I am already signed up for the Curbside Recycling Program.
    3. I am not interested in the Curbside Recycling Program.
19. Account will be billed quarterly beginning the first utility bill after service starts.
21. I understand that the charges for the services requested in this application will be added to the property owner's utility bill once the application has been processed. Charges will continue to be billed until such time the property is sold or a request for cancellation of voluntary services has been submitted to the City of Rock Island. Failure to pay any of the fees associated with these programs could result in immediate termination of the voluntary service.*

    1. Yes
    2. No
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit Submit and Print

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