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Apply for Backdoor Recycling and Refuse Service

2. Address or Location of Pick Up*

4. Agreement
   I am requesting that the City of Rockville provide me with backdoor service, at no additional charge, for my recycling and refuse collections. I am unable to transport my carts to the curb or alleyway and there is no one in my household who is able to transport them for me.

   I am requesting that the City of Rockville provide me with backdoor service, at no additional charge, for my recycling and refuse collections. I am unable to transport my carts to the curb or alleyway and there is no one in my household who is able to transport them for me.

6. I understand that it is necessary to reapply for this service each year. I also understand this service is based on my inability to take my recycling and refuse carts to the curb or alleyway.

   I understand that it is necessary to reapply for this service each year. I also understand this service is based on my inability to take my recycling and refuse carts to the curb or alleyway.

8. First Name*

9. Last Name*

11. Phone Number*

12. Email

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14. 1. Receive an email copy of this form.
15. Email address

    This field is not part of the form submission.

16. Submit

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