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Recycling Division Special Service Questionnaire <br />(To be completed by the person requesting service or their representative) <br />Name of Applicant: <br />Current Address: <br />Phone Number: <br />Age: (if age is basis of request) <br />PLEASE PRINT CLEARLY <br />Best Time of Day to Call: <br />Number of Persons Living in Household: <br />Ages of Additional Person(s) Living in Household: _ <br />Who routinely places your recyclables out for collection now? <br />Do you have a Handicapped Parking Tag? Yes _ No <br />Tag Expiration Date: <br />Reason for Requesting Special Collection Service: <br />Today's Date: <br />Signature: _ <br />Roll Cart or Bin Site Visit By: <br />If yes, Serial # on Tag: <br />Recycling Division Only <br />Circle <br />Approved Yes By: <br />Location of container for collection: <br />No If no, why not approved? <br />Date: <br />Date Approved: <br />R <br />