Orange Village

APPLICATION FOR SNOW REMOVAL SERVICES
(An application must be completed every year)
Orange Village Code Chapter 1026

Please Answer All Questions

 _______________________________________________
Applicant's name:

_______________________________________________
Address:

____________________          _____________
Phone:                                       Applicant's Date of Birth:

Each answer must be answered true (T) or false (F),
_______65 years of age or over.
_______Disabled or medically handicapped.If true, list disability__________________
_______*Annual household income from all all sources is less than $22,150 per year.
_______No able-bodied person resides at the above address.
Name of resident Age Employer *Annual Income
. . . .
. . . .
. . . .
APPLICANT AND EACH ADULT RESIDENT OF THE HOUSEHOLD MUST READ AND SIGN THE FOLLOWING STATEMENT AND RELEASE
I/we hereby certify that the information contained in this application is true and correct to be best of my/our knowledge.

I/we have read the attached bulletin, understand and agree to its provisions.

The undersigned hereby agree(s) that in consideration of snow plow removal services to be provided by Orange Village: he/she/they will hold harmless and release Orange Village, its officials, employees and agents from any and all suits, claims or damages which may arise as a result of snow plow removal services rendered on the premises of the undersigned for his/her/their convenience and waive any claim on his/her/their behalf arising from said Village services.

Applicant's signature________________________Date:___________
Signature of Adult Resident of Household_______________________
Signature of Adult Resident of Household_______________________
For Orange Village use Only Date:
Application received by: ________
Snow removal service approved by: ________
Applicant notified ________

* Applicant must submit copies of last year's U.S. Income Tax Return for all adult residents of household. A disabled or medically handicapped applicant must also submit a doctor's letter indicating disability. Applicants 65 years of age or older must submit a copy of his/her birth certificate.