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2. 
4. CUSTOMER NAME *
5. EMAIL ADDRESS*
7. SERVICE ADDRESS *
8. VERNAL, UTAH 84078
10. PHONE NUMBER *
11. ADDITIONAL PHONE NUMBER *
13. NUMBER OF ADDITIONAL GARBAGE CANS
    -- Select One --123

    Additional garbage cans must be kept for a minimum of 6 consecutive months

15. RENTAL AGREEMENT*

    1. By checking this box, I am signifying that the name provided at the top of this page is my electronic signature and I have read and agree with the following disclaimer:

    I hereby agree to rent automated garbage can(s) from G & H Garbage. I agree to pay an additional monthly rental fee per can. Said fee to be added to my monthly utility bill from Vernal City. The monthly fee per can is for one (1) month or any part thereof remaining at the date of this agreement and I must rent the can for a minimum of six (6) consecutive months. I understand that the garbage cans are the property of G & H Garbage and that I do not have any right to remove said cans from the address listed on this agreement.

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17. 1. Receive an email copy of this form.
18. Email address

    This field is not part of the form submission.

19. Submit Submit and Print

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