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*

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

Estimated monthly tonnage of solid waste to be delivered

Please enter a value between 0 and 5000000.

Estimated monthly tonnage of commercial/industrial solid waste to be delivered

Please enter a value between 0 and 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

Truck Listing

Year	Make	Body Type	Cubic Yards	Legal Weight Limit	Color	Tag Number	Used For Residental or Commerical use?	Used For Recycling (Yes/No)

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*

Charge Account Application