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2. 
4. Date of Closing*
   Date of Closing
5. Type of Resident

   1. Property Owner
   2. Renter
7. Primary Phone:*
8. Secondary Phone:
9. Email Address:*
11. Property Owner Name(s):*
13. Service Address:*
15. Mailing Address:*
17. Driver License Number:*
18. State:*
19. Expiration Date:*
    Expiration Date:
21. Weekly Frederick Flash email letter!

    1. Yes
    2. No

    Stay connected with the Town by receiving our weekly email newsletter.

23. By typing in my name on this form below, I acknowledge and allow the Town of Frederick to contact me regarding any maters regarding my account including by phone, email and/or automated service.
25. ***A $10.00 Connection Fee will be applied to the first month's billing statement.***
27. Applicant's Signature*
28. Date*
    Date
30. Applicant's Signature
31. Date
    Date
33. ****For Office Use Only****
35. Set-up Bin Delivery:
36. Apply Connection Fee:
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field