HomeMy WebLinkAbout(0022) Redbox GOP Application 2021.pdfFORT WORTH. APPLICATION FOR
NON-EXCLUSIVE PRIVILEGE AGREEMENT
(('ollection and Trans ortation of Munici al Solid Waste)
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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
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Physical Address
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Contact Name
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Contact
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Mailing Address
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Telephone Number ,')1,I�.0 !ppq
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Fax Number
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. Do each of the vehicles listed in question 2 above have a current City p�
of Fort Worth HaulingPermit? A
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 auth rized by the Company to sign t is Application
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Title Date
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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