William R. Coffin & Sons, Inc.

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Name               :
Mailing Address    :
Mailing Address    :
Town               :
State              :
Zip                :
Country            :
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Pickup Address     :
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Pickup Town        (___) Harwich          (___) Dennis
                   (___) Yarmouth         (___) Brewster
                   (___) Chatham          (___) Orleans
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Location           (___) Backdoor         (___) Roadside
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Schedule           (___) Twice per week   (___) Once per week
                   (___) Every-2-weeks    (___) Every-3-weeks  
                   (___) Once per month   (___) "On Call"
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Do you wish to use our 95-gallon barrels? (___) Yes          (___) No
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Do you need yearround service?            (___) Yearround    (___) Seasonal
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If seasonal, what
is your time frame?:
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By default, accounts are set up with "Measured" service.  All trash is taken
and charged in multiples of our 2 barrel/1 toter rate.  If you would rather
have "Restricted" service (where you are limited to a pre-specified maximum
amount of trash, with overages left behind) check here ----> (___) Restricted
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Phone              :
Phone              :
Fax                :
E-mail             :
Send mail via      (___) Mail             (___) E-mail
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