Solid Waste Special Collection Request Form

Public Works Department
1815 9 TH Street,
Douglas, Arizona 85607
Telephone (520) 417-7329
Fax (520) 417-7174

If you are an individual who is elderly and/or disabled and unable to get assistance to place your garbage
cans at the curb for collection, you may request that your refuse collection driver retrieve the can from
your home, roll it out for service, and then place it back in its original location. Please fill out this form if
you are interested in receiving this service.

Applicant Information

Name of Individual Seeking Assistance*

Birthdate*

Service Address:*

Mailing Address (If different from above)

Phone Number*

Email Address

Reason For Requiring Service

I am disabled (If disabled please provide Social Security Disability Benefit Verification Letter)

I am elderly (If elderly please describe reasons for assistance)

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Applicant’s Verification of Age or Disability and Household Occupancy

I, the undersigned applicant, certify that I am unable to push my garbage can to the curb. I also certify that there is no one in my household, in my employ, or providing in-home assistance to me from a third party that is able to get my can to the curb. I understand that it is my responsibility to re-submit this form annually every January for the continuance of the Solid Waste Special Collection service. I understand that: My street address must be clearly displayed and visible from the curb, cans may not be placed more than 25 feet from my house, cans may not be affixed unless the qualifying reason is blindness, and there must be a clean and clear path to the collection location.

Signature of Applicant:*

Date