Special Needs Application

2. This application applies only to those households where no one is physically able to roll the garbage can to the street or have any other exceptional reasons as to why the City should provide this service.

4. Date*
   Date
6. Name*
8. Address*
10. Apartment/Unit #
12. Phone*
14. Email
16. Name And Ages Of All Persons Living In This Household
18. Reason Why Special Needs Garbage Collection Is Requested*
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit Submit and Print

* indicates a required field