[Manatee County Government] Medical Rear Door

APPLICATION FOR MEDICAL REAR DOOR SOLID WASTE SERVICE

In accordance with the Solid Waste Franchise Agreements, the hauler shall provide back door or side door service to residences occupied by persons physically incapacitated and unable to transport refuse to the curb without an additional charge.

Applicants for such service shall provide medical proof of such physical incapacity to the County and assurance that no able-bodied person resides at the Residence and there are no more than two individuals residing at the Residence. The following information is necessary to qualify for the handicapped service and rate.

Phone Number

I am unable to place my garbage and recycling containers at the curb due to the following physical limitation, disability, or handicap. (Please attach doctor’s certification.)

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Is the physical limitation, disability or handicap stated above a permanent or a temporary condition?

Permanent

Temporary

If the physical limitation, disability, or handicap is temporary, how long do you anticipate the condition will exist?

How many individuals reside at the residence?

What are the ages of the individuals residing at the residence?

Are any of the individuals reasonably able to transport the garbage and recycling containers to the curb?

Yes

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Your application will be reviewed, and a staff member will contact you regarding approval or denial.