2. Customer Name*
4. Customer Service Address*
5. City, State, Zip*
7. Customer Mailing Address
   (if different from Service Address)
8. City, State, Zip
10. Daytime Phone Number*
11. Email Address*
13. Service Option (please check)*

    1. New Construction
    2. Cancellation*
    3. Residential garbage service ($15.40 per month, effective 1/1/2018)
    4. Commercial garbage service ($20 per month)
    5. Additional 96 gallon garbage cart ($70 one-time fee)
    6. Resume garbage service
    7. Request for recycle cart (64 gallon)
    8. Request for recycle cart (96 gallon)
    9. Repair/replace garbage cart**
    10. Repair/replace recycle cart**
15. Service Start Date*
    Service Start Date
17. *Forwarding Address for Service Cancellation
18. *City, State, Zip
20. **Reason for repair/replace cart request
22. Last 4 Digits of Social Security Number*

    This information is used strictly to verify your identity with Daphne Utilities for billing and/or customer service purposes.

24. Thank you for your business! Please leave your cart at the residence if you move/relocate. Failure to leave cart at residence location will result in a $70 replacement fee and will be applied to your final utility bill for that address/service location. Your digital signature below is your agreement to these terms.

26. Digital Signature*
27. Digital Signature Date*
    Digital Signature Date
Leave This Blank:


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

    This field is not part of the form submission.

31. Submit

* indicates a required field