PRAIRIE BAND POTAWATOMI NATION Return To Site Trash Service One Time Credit Card 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. Are you a New Customer Existing Customer?*Please Choose OneNew CustomerExisting CustomerApplicant 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 Enrollment # 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 Secure Credit Card Card Holder* Card Number* Card Expiration* Card CVV* Convenience Fee $0.00 Total $0.00 CAPTCHAFor Office Use OnlySignature of Division Official Date
