Please read and submit the required information below. By entering the numerical code immediately above the Send Button and by clicking on the Send Button you are agreeing to all Terms and Conditions set forth below.
AUTOMATIC DEDUCTION AUTHORIZATION AGREEMENT
Credit Card Balances will be charged between the 12th and 17th of the month prior to service.
Name(s): (as on card)*:
Billing Address*:
Billing Address (cont'd):
Billing City*:
State*:
Billing Zip Code*:
Phone*:
Email*:
County Waste Acct #*:
Date (mm/dd/yyyy)*:
Credit Card Type*:VisaMaster ChargeAmexDiscover
Credit Card Number*:
Exp Date (mm/yyyy)*:
3 or 4 Digit Code on back of card*:
By submitting this form I agree to all terms and conditions stated above.
This form has spam control within it --- you must type in the code below to send it!
We will respond within 24 hours or on the next business day.
First Name*:
Last Name*:
Service Address*: Phone*:
Question?*:
County Waste | 1927 Route 9, PO Box 431, Clifton Park, NY 12065 | (518) 877-7007 or (888)-54-WASTE | Monday – Friday 7:30am-5:00pm © 2008
