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TRANSFER STATION ACCOUNT APPLICATION
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FAIRBURY TRANSFER STATION ACCOUNT APPLICATION
BILLING INFORMATION
FEIN #:
FOR SECURITY PURPOSES, do not enter the FEIN # and submit electronically. Please complete this at the time of submission to the City Clerk's Office. Thank you.
Date
*
Date
Name
*
Email Address
*
Phone Number
*
Billing Address
*
City & State
*
Zip Code
*
TERMS: I agree to pay the City of Fairbury for all charges incurred for services rendered at the Transfer Station (checks payable to Fairbury Transfer Station). I understand invoicing is monthly and payment is due upon receipt.
SIGNATURE
Date
IDENTIFICATION VERIFICATION:
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