Backdoor Collection Application Check the reason(s) that apply to your situation: I am physically unable to carry my trash and recycling to the curb, and there is no one residing in my household who is able to carry the trash to the curb for me. I no longer need backdoor service; please discontinue the service. I understand I may reapply if my situation changes in the future. (Examples might include an able-bodied person who is living with you now or a friend or neighbor who is helping you). If your pickup is not convenient at your back door, please note the location where your pickup will be:I understand it is necessary to reapply for this service each year. I also understand this program is based on the inability to take trash and recycling to the curb and that is not intended as a routine service for those 65 or older who are able to perform the task. I also understand that these collection services are being provided by American Disposal Services on behalf of Arlington County.Name* First Last Date* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone*Collection Day*Please be aware that information submitted through an Arlington County Government website is considered to be a Public Record under the Virginia Public Records Act and may be subject to release by the County in response to a request made under the Virginia Freedom of Information Act. Do not submit any unsolicited personally identifiable information including (but not limited to) your: (1) social security number; (2) driver's license number; (3) bank account numbers; (4) credit or debit card numbers; (5) personal identification numbers (PIN); (6) electronic identification codes; (7) automated or electronic signatures; or (8) passwords; or (9) any other numbers or information that can be used to access your assets, obtain identification, act as identification, or obtain goods or services. Arlington County may withhold your name and contact information in accordance with the Virginia Freedom of Information Act. Please indicate, by checking the box below, if you would like for the County to seek to keep this information confidential. Please do not disclose my name and contact information in response to a request under the Virginia Freedom of Information Act. I recognize that the County cannot guarantee the confidentiality of my name and contact information but ask that it do so to the extent permitted by law. CommentsThis field is for validation purposes and should be left unchanged.