test - River City Disposal - River Falls, Wisconsin

Customer Name

Dumpster Site Address

Address Line 1

City

State

Zip Code

Requested Dumpster Location

Requested Dumpster Size

On-site Contact Name

On-site Contact Phone

On-Site Contact Email

Billing Address

Address Line 1

City

State

Zip Code

A/P Contact Name

A/P Contact Phone

A/P Contact Email

Autopay with ACH or Credit Card Yes or No?

Yes
No

Routing Number

Account Number

or

Full Credit Card Number

Expiration Date

Full Name on Credit Card

Security Code

Electronic Signature

I authorize River City Disposal, Inc to charge my monthly statement amount to the account provided. River City Disposal, Inc. is not liable for damage of any nature or kind incurred by my request to move past the curb line or right away limits.

Date