City of Henagar Sanitation and Public Works Department
Application for Sanitation Services
Email address *
Applicant Full Name *
Your answer
Service Address *
Your answer
Mailing Address *
Your answer
House Description *
Your answer
Requested Start Date *
MM
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DD
/
YYYY
Number of Cans *
Primary Phone Number *
Your answer
Secondary Phone Number *
Your answer
Driver's License Number *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Email Address
Your answer
Employer Name *
Your answer
Employer Phone *
Your answer
Employer Address *
Your answer
Do you own the service property? *
If renting, Landlord name *
Your answer
Spouse Full Name *
Your answer
Spouse Phone Number *
Your answer
Spouse Employer Name *
Your answer
Spouse Employer Phone *
Your answer
Other Household Occupants *
Your answer
PLEASE READ AND ACCEPT BY ANSWERING BELOW: I hereby accept full responsibility for this account and am aware that I am fully responsible for any amounts due on said account effective this date and until such time as I close this account. **All sanitation services are billed in ADVANCE on a 3 MONTH BASIS** *
Date of Application *
MM
/
DD
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YYYY
A copy of your responses will be emailed to the address you provided.
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