Form Center

2. Resident's Statement
4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Terms

    In accordance with the following physician verification, I am physically unable to transport my household garbage container to the curb collection. I further verify that no able-person residing or working at my residence is capable of transporting my refuse to the curb collection.

17. Resident Signature*
19. Phone*
21. Date*
    Date
23. Physician Statement*

    1. It is my professional opinion that his/her disability is permanent.
    2. It is my professional opinion that his/her disability is temporary.
25. It is my professional opinion that*

    (Please Fill out above) is physically unable to transport his/her household refuse container to the curb for collection. 

26. The temporary disability is anticipated to end: *

    (Please fill out above). 

28. Physician Signature: *

    (Please fill out above)

30. Phone Number:

    (Please fill out above)

32. Address1
34. City
35. State
36. Zip
38. Upload Physician Office Stamp
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

* indicates a required field