MEDICAL EXEMPTION FORM FOR GARBAGE PICKUP

CITY OF FLORENCE, ALABAMA
Solid Waste and Recycling Department

Please have your primary care physician complete the medical exemption form for this request.

Medical Exemption Form

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date:

Resident Signature:

Clear Signature

PHYSICIANS STATEMENT

Please upload a statement from your physician confirming your inability to physically roll a garbage cart to the curbside due to medical reasons with (Physician signature) *

Drag & Drop Files, Choose Files to Upload

29485 County Road 14 * Florence, AL 35633
Phone (256) 760-6495
Fax (256) 740-4665

Enter the Correct Answer *

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CITY OF FLORENCE, ALABAMA
Solid Waste and Recycling Department

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CITY OF FLORENCE, ALABAMA Solid Waste and Recycling Department

CITY OF FLORENCE, ALABAMA
Solid Waste and Recycling Department