|
UPPER DEERFIELD TOWNSHIP
CONVENIENCE & RECYCLING CENTER |
|
APPLICATION FORM |
|
|
|
|
|
|
|
|
|
Applicant's Information ( please print clearly): |
|
|
|
|
|
|
|
|
|
|
|
|
|
Property Owners Name: |
|
|
|
|
|
|
|
|
First Name(s) |
|
Last Name(s) |
|
|
|
|
|
|
|
|
|
|
Tenants Name (if applicable): |
|
|
|
|
|
|
|
|
First Name(s) |
|
Last Name(s) |
|
|
|
|
|
|
|
|
|
|
Property Address: |
|
|
|
|
|
|
|
Block __________ |
|
|
Home
Telephone No.: |
|
|
|
Lot _______ |
|
|
Cell
Telephone No.: |
|
|
|
|
|
|
|
|
|
|
|
Do
you, the applicant, own or rent the above property? |
|
own |
|
rent |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Vehicle Information on
which the Convenience Center Sticker will be placed: |
|
Vehicle #1 |
|
|
|
|
|
|
|
Make
_____________________________ |
Model
Type |
|
|
|
|
|
|
|
|
|
|
|
|
Year
____________________ |
Color |
|
|
License Plate No. |
|
|
|
|
|
|
|
|
|
|
|
Vehicle #2 |
|
|
|
|
|
|
|
Make
_____________________________ |
Model
Type |
|
|
|
|
|
|
|
|
|
|
|
|
Year
____________________ |
Color |
|
|
License Plate No. |
|
|
|
|
|
|
|
|
|
|
|
I understand that I can only
dispose of items which are within my residence listed above in the Township
of Upper Deerfield. I also understand that if any of the above information
is falsified or I violate the rules and regulations governing the use of the
convenience center and/or the sticker then said sticker may be revoked and
deemed invalid. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(property owner's
signature) |
|
(date) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(tenant's signature - if
applicable) |
|
(date) |
|
|
|
***************************************************************************************************************************** |
|
FOR OFFICIAL TOWNSHIP USE -
DO NOT WRITE BELOW |
|
|
|
|
|
|
|
|
|
|
|
|
Sticker (circle one) 1 |
2 |
R |
|
|
|
|
|
|
|
|
|
Date
of Issuance: |
|
|
Cost
(if applicable) |
$10.00 |
$10.00 |
|
|
|
|
|
|
|
|
|
Approved By: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
ID
Verified: |
YES |
NO |
Registration Copied |
YES |
NO |
|
|
|
|
|
|
|
|
|
Vehicle#1 - Sticker No. |
|
|
|
Vehicle#2 - Sticker No. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|