PRAIRIE BAND POTAWATOMI NATION

Tire Disposal Credit Card Payment

CLICK HERE to download form & fill out at a later date

TIRE DISPOSAL APPLICATION

All requests for tire disposal removal are to be made through the PBPN Division of Planning & Environmental Protection and will only serve residents of the Potawatomi Reservation.

Please note: Quantity of tires is required at time of application submission.

Reduced Rate Requirements – Must meet all four requirements:

Must reside on the Reservation
Must be listed as head of household/owner of home
Must be 62+ years of age
Tribal member of PBPN

A one-time fee exemption will be allowed per application annually.

If you do not meet the above requirements, then the following policies apply:

$2.50 per tire

Payment is due at time of request.

No refund will be issued once items have been removed.
Only quantity stated will be removed for disposal.
Staff reserves the right to assess quantity and re-evaluate the cost of service.

Payment Details
*This information is required
Applicant Name*
First Last
Date*
MM slash DD slash YYYY
Phone*
Applicant Address*
Street Address Address Line 2 City State ZIP Code
Applicant Signature*
Reduced Rate Section (Reduced rate guidelines listed ABOVE)
Are You Applying For Reduced Rate?*
- Yes
- No
Applicant is a PBPN Enrolled Member*
- Yes
- No
Enrollment #
Tire Disposal Information
*This information is required
Number of Tires to be Disposed*
Price: $2.50
Descriptive Location of Tires for Disposal - Example: East of fence, or end of driveway, be specific as possible*
Billing Details
*This information is required
Email*
Billing Address*
Same as Applicant Address

Street Address Address Line 2 City State ZIP Code
Secure Credit Card

Card Holder*

Card Number*

Card Expiration*

Card CVV*
Convenience Fee
$0.00
Total
$0.00
CAPTCHA
For Office Use Only
Eligible for Reduced Rate
- Yes
- No
Date Received
Payment Type
Number of Tires @ $2.50
Date of Removal
Reassessment
- Yes
- No
Staff Signature

PRAIRIE BAND POTAWATOMI NATION

Tire Disposal Credit Card Payment

Payment Details

Reduced Rate Section (Reduced rate guidelines listed ABOVE)

Tire Disposal Information

Billing Details

For Office Use Only