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2. Sign-Up for a City of Peoria Trash Cart

   Each household is allowed one trash cart

4. First & Last Name*
6. Address*

   Street Address

8. City
10. Zip Code
12. Phone*
14. Email*
16. Reason for Request*
    -- Select One --New move-in / new occupantCart missing / stolenCart broken / damagedOther - please specify
18. Comments and / or Please Specify Reason for Other*
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field