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2. 
3. FAIRBURY TRANSFER STATION ACCOUNT APPLICATION
5. BILLING INFORMATION
7. FEIN #:
   FOR SECURITY PURPOSES, do not enter the FEIN # and submit electronically. Please complete this at the time of submission to the City Clerk's Office. Thank you.
8. Date*
   Date
10. Name*
11. Email Address*
12. Phone Number*
14. Billing Address*
15. City & State*
16. Zip Code*
18. TERMS: I agree to pay the City of Fairbury for all charges incurred for services rendered at the Transfer Station (checks payable to Fairbury Transfer Station). I understand invoicing is monthly and payment is due upon receipt.
20. SIGNATURE
21. Date
23. IDENTIFICATION VERIFICATION:
25. 1. Drivers License
    2. Government Issued ID
    3. Current Utility Invoice
26. Verified by:
27. Title

    1. City Clerk
    2. Deputy City Clerk
    3. Development Svcs Director
28. Date
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

* indicates a required field