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.