2. YARD WASTE SUBSCRIPTION PROGRAM APPLICATION

4. Pickup Location Address*
5. Utility Account #
7. PRIMARY YARD WASTE SUBSCRIBER
9. Yard Waste Subscription Program ($100 per season billed at $25 per quarter/no cart)*

   1. Please sign me up for the Yard Waste Subscription Program as the primary subscriber. Yard waste will be collected at the pickup location address listed above.
   2. I am not interested in the Yard Waste Subscription Program as the primary subscriber.
11. Yard Waste Cart for Primary Subscriber ($12.50 per quarter/96 gallon cart) - Must have yard waste subscription to receive cart.*

    1. As the primary subscriber, I would like to receive a 96 gallon yard waste cart.
    2. I am not interested in receiving a yard waste cart as the primary subscriber.
13. Property Owner Name (Primary Subscriber)
15. Property Owner Address (Primary Subscriber)
17. Property Owner Phone Number (Primary Subscriber)
19. NEIGHBOR SHARING YARD WASTE SUBSCRIPTION
21. Multiple neighbors may share a single yard waste subscription as long as the yard waste is placed in one location (primary subscriber address). The neighbor may also rent a yard waste cart and share with the primary subscriber of the yard waste subscription.
23. Yard Waste Cart for Neighbor Sharing with Primary Subscriber ($12,50 per quarter/96 gallon cart)

    1. I would like to receive a 96 gallon yard waste cart. I am the neighbor sharing the yard waste subscription. My information is listed below.
25. Primary Subscriber Address
27. Name of Secondary Subscriber (Neighbor of Property Owner)
28. Address of Secondary Subscriber (Neighbor of Property Owner)
30. Phone Number of Secondary Subscriber (Neighbor of Property Owner)
32. The yard waste collection season typically runs the first week of April to the first week of December. Primary subscribers will receive a letter each year with the exact dates of the season and 10 yard waste stickers.
34. The property owner will be billed each quarter beginning on the first utility bill after the service starts. There will be a $25 service charge if a customer reapplies for the Yard Waste Subscription Program within 12 months of cancellation.
36. 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:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

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