Registration Form for Household Hazardous Waste Collection Event

Thank you for your interest in this event.

Please note that all information requested must be filled out completely.  Incomplete forms will not be eligible to participate.  Please return the form to jliberman@roswellgov.com or Roswell City Hall, 38 Hill Street, Suite 235.  All forms must be in by May 13th at 5:00 p.m.

Name:  _________________________________________

Address:  _______________________________________

City, Zipcode:  ___________________________________

Daytime Phone:  ________________________

Evening Phone:  _________________________

Email:  __________________________________________

Have you included a copy of your Drivers License/City of Roswell Sanitation Bill?  CircleYes No

If no, please take the form back and return it with a copy of your license/City of Roswell Sanitation Bill.

Products I plan to bring to event: (items you list below are the only items that will be accepted)

Latex PaintAmount in pounds _______________

Solvent Based PaintAmount in pounds _______________

Paint Varnish and RemoversAmount in pounds _______________

Thinner/TurpentineAmount in pounds _______________

Wood PreservativesAmount in pounds _______________

(These are the only materials that will be accepted.  Weight must be specified accurately.)

I certify that the information above is complete to the best of my knowledge.  I certify that I am a resident of the City of Roswell as defined for this event – physically residing within the city limits of Roswell.  I also understand that I should check my email for the details of the event if I am selected to participate.  I understand that participation is limited due to limited funds and that I may not be able participate at this event in 2008.

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