New Customer Establishment Form

"*" indicates required fields

Billing Information

Billing Address*

Billing Street Address City State ZIP Code

Billing Contact Name*

Office Phone*

Cell Phone*

Email*

Fax

Please enter one of the following:

D-U-N-S #

Federal Tax ID

D-U-N-S #

Federal Tax ID

Billing Preference*

Preferred Payment Method*

*Is your company able to pay Discount Waste, Inc. within the agreed upon payment terms WITHOUT relying on receipt of payment from your customers?*

Yes

If no, please explain in detail why:*

Tax Exempt

Is your company tax exempt in any state?*

Yes

If yes, please provide copies of all related tax certificates.*

Drop files here or

Max. file size: 32 MB.

Principal Officers

Name

Title

Phone

References

Please provide at least 4 trade references, including 3 waste service references if available.

*Please DO NOT list Waste Management, Allied/Republic Services or any Waste/Equipment Broker.

Reference 1*

Company Name Contact Name Email

Reference 1*

Street Address City State ZIP Code

Phone*

Fax

Account #

Reference 2*

Company Name Contact Name Email

Reference 2 Address*

Street Address City State ZIP Code

Phone*

Fax

Account #

Reference 3*

Company Name Contact Name Email

Reference 3 Address*

Street Address City State ZIP Code

Phone*

Fax

Account #

Reference 4*

Company Name Contact Name Email

Reference 4 Address*

Street Address City State ZIP Code

Phone*

Fax

Account #

Bank Information

Bank Name*

Contact Name*

Phone

Fax

Signature

Applicant understands that the above information is given for the purpose of obtaining credit. By signing below applicant authorizes Discount Waste, Inc. to make credit inquiries to the above listed references.

Date

Name

Name Title

Comments

This field is for validation purposes and should be left unchanged.