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Charge Account Application

Applicant (Individual or Firm Name)*
- Corporation
- Partnership
- Sole Proprietorship
- Limited Liability Corporation
State of Origin*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone*
Fax
Email*
Would you like your statements emailed?*
- Yes
- No
Type Of Business*
Years In Business*
Name of Predecessor Businesses
Contact Person For Invoices*
Email*
Phone*
Parent Company
Parent Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent Company Email
Parent Company Phone
Parent Company Fax
Federal ID #*
DE Business License #*
Information On Principals
Name Home Address Phone Social Security No. Position

For Proprietorship or Partnership: List All Owners and or/Partners
For Corporation or Limited Liability Company: List all Officers Directors
Have any of the companies prinicpals listed above ever been a debtor in a bankruptcy proceeding?
Has any judgement ever been entered against any of the companies principals listen above?
Are there any legal actions or arbiitration pending against any of the companies or principals listed above?
If you answered yes to any of the three questions above, please provide an explanation and current status
Trade References*
Name Contact Name Phone Address Fax Email

**You must submit 3 Trade References**
Please upload separate financial statements of assets and liabilities
Max. file size: 256 MB.
Estimated monthly tonnage of solid waste to be delivered
Please enter a number less than or equal to 5000000.
Estimated monthly tonnage of commercial/industrial solid waste to be delivered
Please enter a number less than or equal to 5000000.
Indicate location(s) where solid waste is being delivered
Type Of Waste Location Delivered
TERMS AND CONDITIONS
Obtaining a DSWA license to collect, transport and utilize Delaware Solid Waste Authority facilities for disposing of solid waste or dry waste does not create a charge account with DSWA. Any private hauler or individual may request a charge account.
- *A completed and signed Delaware Solid Waste Authority Charge Account Application
- *A completed and signed Authorization to release bank information
- *Issuance by a corporate surety, qualified to do business in the State of Delaware, of a Guarantee of Payment Bond (Bond amount to be determined after review of application
- *DSWA reserves the right to run a credit history on any applicant for a charge account and requires the applicant to authorize DSWA to contact and examine banking history and credit references.
I understand that this constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
Name
First Last
Title or Capacity
Date
MM slash DD slash YYYY
Truck Listing
Year Make Type of Vehicle Color Tag # State Fleet Number (if applicable)

Please supply the following information for all trucks
DSWA Customer Credit & Policy & Procedure
Please read the following before completing application DSWA Customer Credit Policy & Procedure
This is to confirm that I as proprietor, partner or Corporate officer of the above mentioned company have examined the DSWA Customer Credit Policy & Procedure , and being familiar with all requirements and conditions agree to operate in accordance with such requirements in the event credit is extended.

I understand that this constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
Name*
First Last
Title*
Date*
MM slash DD slash YYYY

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Year	Make	Type of Vehicle	Color	Tag #	State	Fleet Number (if applicable)

Name	Home Address	Phone	Social Security No.	Position

Name	Contact Name	Phone	Address	Fax	Email

Type Of Waste	Location Delivered