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2. CITY OF ROSWELL
   Landfill Account Application
4. Name of Business or Applicant:*
5. Email Address (if available):
7. Mailing Address:*
9. City:*
10. State:*
11. Zip Code:*
13. Phone Number:*
14. Fax Number:
16. Contractor, Business, or Driver License Number:*
18. Person(s) permitted to charge to account:*
20. Type of Material Disposed of:*
    -- Select One --Construction MaterialsRoofing MaterialsYard DebrisElectronic WasteHousehold Hazardous WasteTiresCardboardMetalHousehold Trash
22. Date submitted*
    Date submitted

    Date submitted
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit Submit and Print

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