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arch logoAutomatic Deduction Authorization Agreement 

 

By filling out and submitting this form, I hereby authorize Solid Waste Disposal Service Inc. to initiate payment deductions from my Visa/MasterCard. Extra trash/items that are collected with regular trash will be charged on the current billing cycle. This Authorization will remain in effect until a written notification is received from the customer, or by termination of services provided by SWDS.

 

To reduce paper waste, you will no longer receive a monthly statement.  

Please fill in all information 

Name on Your SWDS Account:_________________________________________________

Mailing Address:_____________________________________________________________

City:___________________________________________________ Zip Code:___________

Telephone Number(s):_________________________________________________________

SWDS Account Number:______________________________________________________

Customer Signature:_________________________________________ Date:_____________

Credit Card Option

Credit Card Balances will be charged between the 28th and the 2nd of every month following the month of service.

□ Visa     □ MasterCard

Card Holder's Name (print):____________________________________________________

Credit/Debit Card Number: _____________ _____________ _____________ ____________

Expiration Date:______/______   3 Digit CVV2 Code on the back of the card:______________

 

Card Holder's Signature:_______________________________________  Date:___________

 

 

 

 

 

 

 

 

 

 

 

PO Box 250 ● Bloomington, New York 12411 ● Tel. 845-339-1911

 
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