BulkItemCollectionRequestForm
Name:
Address:
Phone:
Email:
I request the following items be collected:
1. ________________________________________________________
2. ________________________________________________________
3. ________________________________________________________
Additional Items:
4. ________________________________________________________
5. _______________________________________________________
6. _______________________________________________________
The City will:
Only collect those items included on this form: Example: (Dining table and 4 chairs = (1) Item;
Mattress/box spring with frame = (1) Item: 3-piece bedroom suite = (3) Items.)
Only collect items placed at the end of driveway or within the tree lawn area next to the driveway.
Items will not be collected if stored in a garage, shed or other out-building, or if obstructed by vehicles
or other barriers.
Method of payment:
Check #________ in the amount of $___________ made payable to “City of Delaware”
Cash paid at Public Works in the amount of $___________. (Exact change is required)
Visa Mastercard American Express Discover in the amount of $____________.
Applicant Signature: __________________________________ Date:_____________________
Office Use
Staff Initials: __________________ Date: __________________ Receipt Provided
YourScheduledCollectiondateis:_______________________________________________
Have items to the curb by or before 7 a.m. the day of collection.
City of Delaware Public Works*440 E. William St.*Delaware Ohio 43015
Phone: 740-203-1810
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