2. Refuse Collection: Special Services
   Special Services are available to qualifying households within the City of Waynesboro. If you (and your spouse) are elderly or disabled and reside in a household in which there is no one physically able to roll the refuse container to the designated pick up location, you may qualify for our special services. The services are provided on a 12-month basis and must be renewed annually.
4. What Special Services are Provided?
   If an individual/household meets the criteria to receive special services for refuse collection, city crews will roll the refuse container to the pick up location for disposal and return the container to the resident’s home.
6. How Do I Qualify for Special Services?
   To qualify for these services an individual/household must meet the following criteria: Reside full time in a house/apartment in which there are no other residents physically able to roll the refuse container to the designated pick up location. Provide a note, if requested, from a physician stating that these services are needed in this household. Currently be receiving Residential Refuse Service as provided by the City of Waynesboro. If you have questions please call Refuse at 540-942-6764
10. Contact Information
12. Are you:

    1. Account Holder

    1. Caregiver

    1. Relative
14. If you are a caregiver or relative, please give your Name and Phone Number
16. Account Holder Information
18. First and Last Name *
19. Utility Account Number (if known)
21. Phone Number*
22. Email Address
24. Street Address:*
26. Refuse Collection: Special Services are requested for the following reasons: *
28. Can Location:*
    -- Select One --AlleyFront of HouseSide of House
30. Renewal of Contract*

    1. I understand that these services are available on a 12-month basis and must be renewed annually.
32. Date and Time
    Date and Time

    Date and Time
33. Signature
37. APPLICATION REVIEW (Solid Waste Management Use Only)
39. After being reviewed, the request for Refuse Collection: Special Services has been...

    1. Approved

    1. Denied

    for______________________________________ service address_______________________________________ If service is denied, give reason:________________________________________________________________________________________ Approved/Denied By__________________________ Date of Review _________________________________ Date Applicant Contacted _________________________ Route Assignment: Route ____________________ Driver _________________________________________ Pick Up Day ______________________________ Effective Date __________________________________
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