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Virginia Waste Services, Inc.

Thank you for choosing Virginia Waste Services, Inc. To complete your transaction, please fill in the information below as it appears on your billing statement. If your service address is different from your billing address, then please complete that section as well. Items with an asterisk are required.

Customer Number* Total Amount*

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Billing Details:

First Name:*

Last Name:*

Street Address:*

City:*

State:*

Zip Code:*

Phone Number:

E-mail address:

Comments:

Service Details:

Please complete if different from billing.

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

You will see a confirmation page once your transaction has been completed.

Please print this for your records. Thank you again for choosing VWS!

	Billing Details:
First Name:*
Last Name:*
Street Address:*
City:*
State:*
Zip Code:*
Phone Number:
E-mail address:
Comments:

	Service Details:
	Please complete if different from billing.
First Name:
Last Name:
Street Address:
City:
State:
Zip Code:

You will see a confirmation page once your transaction has been completed.
Please print this for your records. Thank you again for choosing VWS!