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City of Henagar Sanitation and Public Works Department
Application for Sanitation Services
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* Indicates required question
Email
*
Your email
Applicant Full Name
*
Your answer
Service Address
*
Your answer
Mailing Address
*
Your answer
House Description
*
Your answer
Requested Start Date
*
MM
/
DD
/
YYYY
Number of Cans
*
1 Can (First can will be $18 monthly)
2 Cans (Second can will be an additional $12 monthly)
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?
*
Yes
No
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**
*
I accept
I decline
Date of Application
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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