Request for Curbside Exemption

Name

This field is for validation purposes and should be left unchanged.

Is a new request or renewal of an existing exemption?(Required)

New Request

Renewal

Please select the reason(s) for the curbside exemption request:(Required)

Medical Condition/Disability (for applicants under the age of 65)

Senior Citizen

House/Garage Door Service (Fees Apply)

Applicant Information

Service Address(Required)

Street Address Address Line 2 City State ZIP Code

Applicant Name(Required)

First Last

Applicant Phone(Required)

Applicant Email(Required)

Applicant Date of Birth (MM/DD/YYYY)(Required)

Number of people residing in your household:(Required)

List the age(s) of all people residing in your household:(Required)

List the date of birth of all people residing in your household:(Required)

Property Owner Information

Property Owner's Name(Required)

First Last

Property Owner's Phone(Required)

Proof of Medical Condition/Disability

If applicable, please attach a physician's statement or certification verifying that you are physically unable to take the household garbage and recycling containers to the curb. This is required for applicants under the age of 65.

Accepted file types: allowedtypes:gif, jpg, jpeg, png, doc, docx, xls, xlsx, rtf, pdf, txt, Max. file size: 50 MB.

Proof of Age

If applicable, please proof of age (minimum 65 years old) is required with a driver's license, birth certificate, or other official document showing proof of age; a copy for all people residing in your household is required (No other resident of the household is capable of placing the container curbside for collection)

Accepted file types: gif, jpg, jpeg, png, doc, docx, xls, xlsx, rtf, pdf, txt, Max. file size: 50 MB.

Additional attachments can be emailed.

Signature (Full Name)(Required)

Right of Entry Agreement

Property Address(Required)

Street Address Address Line 2 City State ZIP Code

Name of Owner or Tenant(Required)

Signature (Full Name)(Required)

Curbside Exemption Application

Applicant Information

Property Owner Information

Right of Entry Agreement