E-Statement Request Form

Complete and submit the form below electronically OR you can download our printable form, complete and drop off, mail or fax to our office.

Customer Name*
Customer Phone*
Email*
Enter Email Confirm Email
Service Address
Street Address State ZIP Code
I would like to begin receiving my statements/invoices/notices electronically to the email address stated above. By signing this e-statement request form I authorize Perry’s Solid Waste Disposal to email all future statements/invoices/notices.
Customer Signature*
Date Form Submitted*
MM slash DD slash YYYY