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2. Name*
3. Email Address*
5. Address of Property Requesting Additional Services*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Date To Start Additional Services*
    Date To Start Additional Services
14. Type of Services Requested*

    Trash or Recycle bin? 

15. Quantity Requested*
17. Note
19. *Information

    The cost for an additional trash bin is $9.00 per month and $6.00 per month for a recycle bin. These fee's will be added to your Utility bill.

    This application is an exclusive contract between the City of Clearwater, Sedgwick County, Kansas, and the applicant at the above address. The applicant agrees to be responsible for all payments for the additional trash services at the above address from the date service under this application is commenced until service is terminated by notice.

    
    

    
    

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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit Submit and Print

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