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TRANSFER STATION ACCOUNT APPLICATION

2. 

3. FAIRBURY TRANSFER STATION ACCOUNT APPLICATION

5. BILLING INFORMATION

7. 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.

8. Date*
   Date

10. Name*

11. Email Address*

12. Phone Number*

14. Billing Address*

15. City & State*

16. Zip Code*

18. 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.

20. SIGNATURE

21. Date

23. IDENTIFICATION VERIFICATION:

25. 1. Drivers License
    2. Government Issued ID
    3. Current Utility Invoice

26. Verified by:

27. Title

    1. City Clerk
    2. Deputy City Clerk
    3. Development Svcs Director

28. Date

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

* indicates a required field