Commercial/Institutional Keycard Registration Form

First Name *

Last Name *

Address *

City *

State *
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Zip *

Home Phone *

Alternate Phone

Email *

Drivers' License Number *

Max 10 vehicles/trailers, must be registered to a listed entity:

I certify that I am the owner/tenant/responsible party of the above-listed property within the City of Williamsport, and I have read the attached rules and regulations and hereby agree to follow all rules and regulations pertaining to the City of Williamsport Brush/Mulch Recycling Collection Area and key card registration. I understand that violation of any of these rules and regulations will result in forfeiture of privileges to use the Brush/Mulch Recycling Collection Area and termination of key card access. I agree to make known to the household member (additional responsible party) listed, the terms and conditions for use of the Brush/Mulch Recycling Collection Area and key card access and agree to take responsibility for their actions while using my key card. Additionally, I acknowledge the above information is true and correct.

Applicant Signature: