Request for Service - Residential

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Name(*)

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Phone (XXX-XXX-XXXX)(*)

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Email(*)

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Fax

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Birthday (MM/DD/YYYY)(*)

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Drivers License #(*)

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Service Address

Service Address(*)

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City/State(*)

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Zip(*)

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Directions / Nearest Crossroads

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Billing Address if different that Service Address

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Spouse Information (if applicable)

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Social Security #

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Relative Information (if applicable)

Closest Relative's Name

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Address

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Do you own or rent?(*)

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If Renting - please provide the Owners Information

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Employer Information

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Have you ever filed bankruptcy?(*)

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Personal References (please provide 3 references)

Name(*)

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Address(*)

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City/State/Zip(*)

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Phone (XXX-XXX-XXXX)(*)

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Name(*)

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Address(*)

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City/State/Zip(*)

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Phone (XXX-XXX-XXXX)(*)

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Name(*)

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Address(*)

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City/State/Zip(*)

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Phone (XXX-XXX-XXXX)(*)

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Auto Payment (*)

Yes, I would like to signup for Auto Pay
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Terms of Service

TERMS: NET 30 DAYS. ACCOUNTS NOT PAID BY THE LAST BUSINESS DAY OF THE MONTH, FOLLOWING STATEMENT DATE, ARE DELINQUENT AND ARE SUBJECT TO A LATE CHARGE OF 1.5% OF THE DELINQUENT AMOUNT PER STATEMENT PERIOD. THE CUSTOMER IS RESPONSIBLE FOR ANY DAMAGE TO AMERICAN REFUSE’S PROPERTY. THE CUSTOMER IS ALSO RESPONSIBLE FOR THE CONTENTS OF CONTAINER. AMERICAN REFUSE IS AUTHORIZED TO CONTACT ANY REFERENCES LISTED ABOVE.
ALL STORAGE CONTAINER ACCTS 60 DAYS PAST DUE, THE CONTENTS OF S/C WILL BE LIQUIDATED, & ALL COST INCURRED WILL BE PAID BY THE CUSTOMER.

CERTIFICATION: I CERTIFY THAT THE INFORMATION GIVEN ABOVE IS CORRECT. I HAVE READ AND UNDERSTAND THE TERMS AND RATES AS STATED AND AGREE TO PAY THE ACCOUNT IN THE ABOVE NAME WITHIN THESE TERMS. IN THE EVENT I FAIL TO PAY, AND IT BECOMES NECESSARY TO PLACE THIS ACCOUNT IN THE HANDS OF AN ATTORNEY FOR COLLECTION, I AGREE TO PAY A REASONABLE ATTORNEY FEE FOR ITS COLLECTION.

Terms Agreement(*)

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Request for Service - Residential

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