CREDIT CARD AUTHORIZATION FORM
DATE OF FORM: __________
I hereby authorize the Larimer County Landfill to charge landfill fees to the following credit card
issued in my name:
Company Name________________________________________________________________
Company Address___________________________________________________
Company Email____________________________________________________
Contact Name___________________________Phone Number______________
Will another company be hauling for you? Yes_____ No _____
If yes, please indicate all haulers authorized to charge fees to your credit card:
____________________________________________________________________________
Card Information:
Name on card_________________________________________________________________
(print)
Card Number____________________________________________Card expiration________
Signature on card_______________________________________________________________
(please sign)
Larimer County Solid Waste has my approval to use this credit card on the following dates:
Date:______________________ until Date:_________________________
Note: If project extends beyond the above mentioned date a new form will have to be
completed. ****Must have current Operators License to use facility***
Special Instructions:
5887 S Taft Hill Rd, Fort Collins, Colorado 80526, 970.498.5760, www.Larimer.org/solidwaste
Office Use Only:
License______
Gates_______
Acct#_______
