PRAIRIE BAND POTAWATOMI NATION Return To Site Trash Service ACH Payment CLICK HERE to download form & fill out at a later date Payment Details*This information is requiredPolicies & Procedures*The customer agrees to maintain the containers and shall be responsible for all reasonable repairs including parts and labor should malfunctions of damage occur during the service period. Inspection of equipment is encouraged before taking possession. If either party chooses to terminate the service, the containers must be returned to the owner in the condition received. Failure to properly maintain containers or loss of containers will result in a fee assessment of $45.00 Customer grants to the undersigned, PBPN Division of Planning and Environmental Protection, the right to collect and dispose of all of Customer’s Waste Material (which include recyclable materials) and agrees to make the payments, $20 per month, as provided for herein and the PBPN Division of Planning and Environmental Protection agrees to furnish such services and equipment specified above, all in accordance with the terms of this Agreement. Customer agrees to participate in the curbside recycling program by separating all recyclable materials from waste and utilizing issued recycling container. Customer agrees to all of the policies and procedures described herein. Applicant Name* First Last Applicant Signature*Date* MM slash DD slash YYYY Applicant Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is This An Account Holder Transfer?* Yes No Tribal Member & 62 Years or Older (ID Confirmed) Yes Billing Details*This information is requiredTrash Service ($20/Month)* Price: $20.00 Quantity: Email* Phone*Billing Address* Same as Applicant Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Bank Transfer* Account holder Name * Account Number * Routing Number * Account Type * Choose One.. Checking Savings Check Type * Choose One.. Personal Business PAYMENT TERMS AND CONDITIONS*AUTHORIZATION By checking the "I accept the Terms and Conditions" checkbox below I authorize my bank to debit my specified account for the amount of my payment. This is a one-time payment which will occur on the next business day or as soon as practical thereafter. If my payment cannot be completed for any reason, including insufficient funds or error in the information which I submitted, I will retain the same liability, which is my sole responsibility, for payment as though I had not attempted to make the payment. I also understand that additional fees and penalties may be collected to the extent of applicable law. RECEIPT A receipt can be printed after payment is accepted which may serve as evidence of payment. If an email address is provided during the payment process, a receipt will be emailed to you after the payment is processed. CONTACT If for any reason you wish to make a change to the payment after submission, please contact Prairie Band Potawatomi Nation for assistance at 877.715.6789 I agree to the terms and conditions Convenience Fee* Price: Total $0.00 CAPTCHAFor Office Use OnlySignature of Division Official Date
