EmailMe Form - Clean Can King Sign Up Form

Name *
First Last
Email *
Phone Number
### - ### - ####
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Service Plan Selectin *
Monthly-$25.00
Quarterly-$40.00
Bi-Annual-$60.00
Do you have "City" Trash Can Services?
YES
NO
IF YES....Trash Pick Up Day and Time
MM / DD / YYYY HH : MM AM/PM
Date & Time Preference for cleaning *
# Of Trash Cans? *
Residential or Commercial *
Special Instructions