YES! I want to begin receiving my free services right away. Please sign me up for weekly trash pickup with Triumph Disposal Services. I understand I will be billed for service quarterly in advance. Minimum 12 month service commitment for free offer.

Triumph Disposal will send certified vouchers for more than $200.00 in free services once we have processes your service request.

Name
Billing Address
Address (cont.)
City
State
Zip Code
Home Phone
Alternate Phone
(Work, cell, etc.)
E-mail
Physical Address

Directions to your residence

Number of 95 gallon carts requested

Account Information:

Scheduled Pickup Day:

Triumph Disposal will contact you by e-mail with the scheduled day for your area.

Date of First Pick-Up (mm/dd/yy)

Amount Due for first 3 months:

Amount due depends on services requested. Triumph Disposal will e-mail you with the amount due after receiving the information from this form. Keep a copy of the next page for future reference.

Payment Method  MasterCard Visa Discovery Check Money Order
Card numbers are expected when Triumph Disposal contacts you to verify sign-up of services.

Send me free service vouchers for these additional services.

Yes	No
		Better Lock & Key
		Edison Security
		Longview News-Journal
		Parke Way Fitness
		Tyner Electronics - DIRECTV
		Precision Pest Control
		Wingers - An American Diner
		Sydcom Communications

Triumph Disposal will process your order immediately. We will contact you with your collection day schedule and arrange for container delivery. You will receive the free service vouchers by return mail.

From whom did you hear about our services?

Group Account Number

 Not all services available in all areas. Offers are good through July 31, 2001