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2. Jacksonville, Arkansas
   City of Jacksonville, Arkansas

3. This form is to request an additional garbage receptacle. There will be an additional charge of $8 per month added to your water bill, and you will be required to keep the receptacle for a minimum of three months.

5. Additional garbage receptacles MUST be spaced AT LEAST FOUR (4) FEET APART.
7. Garbage receptacles MUST be spaced 
   AT LEAST FOUR (4) FEET from additional carts or other obstructions.
9. Date
   Date

   Date
11. First Name
12. Last Name
14. Address1
16. Address2
18. City
19. Arkansas
20. Zip*
22. Comments
24. Other than Jacksonville, Arkansas
    Please notify proper organization of concerns.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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