HomeMy WebLinkAbout(0145) GOP Application Texas Elite Disposal DK Haney.pdfFoRT W6RTH. APPLICATION FOR
NON-EXCLUSIVE PRIVILEGE AGREEMENT
(Collection and Transportation of Municipal Solid Waste)
INSTRUCTIONS: Complete form and return to City of Fort Worth, Solid Waste Management Division
4100 Columbus Trail, Fort Worth, TX 76133
Trade Name of Applicant
Physical Address
Contact Name
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Mailing Address
A
Telephone Number `a/ 7 - 2
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Fax Number 4 ,
1. Briefly describe the nature and character of the service the applicant proposes to
render.
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2. Estimated Number of Vehicles Operating Under this Agreement:, A list
of all vehicles must be attached to this application. The list shall
include make, model, year and license plate number of all vehicles to
operate under this Agreement. 3
3. Do each of the vehicles listed in question 2 above have a current City
of Fort Worth Hauling Permit? I NO
4. Applicant has attached Certificated of Liability Insurance as required in Circle One
the Non -Exclusive Privilege Agreement, section 13. YES NO
5. Signature of person authorized 4y the Company to sign this Application
Signature &3a,
Title �r�Ges,�,�,,,Date /Z -
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For City Use Only
Privilege Agreement Number: Date Approved:
Period Covered: to Approved M&C Number:
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Distribution: City Secretary, Solid Waste Division, Applicant