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2. Fill out this form to apply for Disability Services for waste collection.
6. Name (First, Last)*
7. Date*
   Date
9. Phone Number*
10. Email Address
12. Address*
14. Physician's Statement
    You can either have the physician fax the statement to us at 561-791-4023 or directly upload it here on the form.
16. File Upload
Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field