Solid Waste Credit Application

Each new customer should submit a waste application and credit application to the Solid Waste Department.

Solid Waste Credit Application

Fields marked with an * are required

* Business Name:

* Business Address:

* Mailing Address:

* City:

* State:

* Zip Code:

* Business Phone:

Fax:

* Cell Phone:

* Email Address:

* Contact Person:

* Type of Organization:

Sole Proprietorship
Partnership
Corporation
Other

* Federal I.D. #

* Describe Business Activities:

* Annual Gross Revenue:

* Approximate Net Worth:

* How many years in business?

Officers of Company:

* Name:

* Title:

* Home Address:

* City:

* State:

* Zip Code:

Name:

Title:

Home Address:

City:

State:

Zip Code:

Name:

Title:

Address

City:

State:

Zip Code:

Bank and Credit References

* Bank Name:

* Bank Address:

* City:

* State:

* Zip Code:

* Phone:

* Account Number:

Bank Name:

Bank Address:

City:

State:

Zip Code:

Phone:

Account Number:

Bank Name:

Bank Address:

City:

State:

Zip Code:

Phone:

Account Number:

* What kind of Solid Waste will your company deposit at the Landfill or Transfer Station?

* County or Counties of Origin:

* How many loads do you expect to dump each month?

The applicant certifies the above information is true to the best of his/her knowledge and agrees to the Credit Policy approved by Daviess County Fiscal Court.

Daviess County Fiscal Court is authorized to obtain, receive, and report credit information regarding this application or resulting account(s).

The applicant will promptly pay for all charges, including any late fees and/or penalties.

* I Agree:

* Authorized Business Signer:

* Today's Date:

* 2nd Authorized Business Signer

* Today's Date:

Solid Waste Credit Application

Install Daviess County Kentucky