Name *

First Name

Last Name

Address *

Address 1

Address 2

City

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I verify that... *

I own the property on which this cigarette waste receptacle will be installed.

I commit to regularly maintaining the cigarette waste receptacle(s) I am ordering.

I commit to participate in the cigarette filter recycling program required by this grant (ship used cigarettes in provided, free packaging rather than throwing away).

If necessary, I will conduct 3 cigarette litter scans (count how many cigarettes are on the ground around the receptacle.)