1

First Name:

 *

First Name:

2

Last Name:

 *

Last Name:

3

Phone:

 *

Phone: ext.

4

Email:

 *

Email:

5

Bulky Item(s) to be picked up:

 *

Bulky Item(s) to be picked up:

6

Pickup location:

 *

Pickup location:

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I understand and agree

• that this application indicates my willingness to pay for service and follow all rules and regulations related to this service
• that this is a NON-REFUNDABLE service; once I submit payment for this service, I will not receive a refund if my bulky item is taken away by someone other than City of Santa Cruz personnel
• that pickup items must be on the curb by 5 am on the day of pickup, and that certain limitations and restrictions may apply which render pickup infeasible or require the applicant to submit further information or payment to complete a pickup request
• to indemnify, defend and hold the City of Santa Cruz, its agents and employees harmless from any claims for damage, death or personal injury which may result from the placement of pickup items, or the pickup of said items, during the course of this service with the City of Santa Cruz. This agreement does not extend to liability arising from the negligence or intentional misconduct of city staff, as determined by court judgement.

 *

I understand and agree that this application indicates my willingness to pay for service and follow all rules and regulations related to this service that this is a NON-REFUNDABLE service; once I submit payment for this service, I will not receive a refund if my bulky item is taken away by someone other than City of Santa Cruz personnel that pickup items must be on the curb by 5 am on the day of pickup, and that certain limitations and restrictions may apply which render pickup infeasible or require the applicant to submit further information or payment to complete a pickup request to indemnify, defend and hold the City of Santa Cruz, its agents and employees harmless from any claims for damage, death or personal injury which may result from the placement of pickup items, or the pickup of said items, during the course of this service with the City of Santa Cruz. This agreement does not extend to liability arising from the negligence or intentional misconduct of city staff, as determined by court judgement.

I understand and agree with the above statements.

Your Initials Here

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