City of Edina Form Center

Garbage Hauler or Recycling License Application

2. Business Name*
4. Contact Person First Name*
5. Contact Person Last Name*
7. Contact Person Email*
8. Contact Person Phone Number*
10. Business Address*
12. City
13. State
14. Zip Code
16. Provide your Minnesota Tax ID Number. If a Minnesota Tax ID Number is not required, explain why. *
17. Provide a Federal Tax ID or Social Security Number.*
19. If application is made on behalf of a partnership, corporation or LLC, please furnish the following:
21. Name of Partner (or Officer) and Title
22. Business Address
24. Name of Partner (or Officer) and Title
25. Business Address
27. Name of Partner (or Officer) and Title
28. Business Address
32. Truck Information
34. All trucks to be licensed must be listed below.
36. Vehicle Year*
37. Vehicle Make and Model*
38. Minnesota License Number*
39. Edina License Number
41. Vehicle Year
42. Vehicle Make and Model
43. Minnesota License Number
44. Edina License Number
46. Vehicle Year
47. Vehicle Make and Model
48. Minnesota License Number
49. Edina License Number
51. For more vehicles, upload additional documents.
    Documentation should include the same information as the above entries.
53. Frequency of Service*
54. Type*

    1. Commercial
    2. Residential
55. Do you provide recycling service?*

    1. Yes
    2. No
59. Fees
61. First Vehicle License Fee
    Base Fee
62. Price
63. Quantity
64. Shipping Cost
66. Additional Vehicles
    Per Vehicle
67. Price
68. Quantity*
    Enter number of additional vehicles to be licensed.
69. Shipping Cost
71. Taxable
73. Taxable
75. Certificate of Insurance*
    ($1,000,000/$1,000,000/$1,000,000)
76. Copy of Rate Schedule*
78. Additional forms needed - You are required to mail in a
    Continuing Bond Form
80. Mail Continuing Bond Form to:
    Edina City Hall, Attn: Jane Timm, 4801 W. 50th Street, Edina, MN 55424
82. I agree to send the Continuing Bond Form to the City. *

    1. I agree.
86. Insurance Company Name
    Please do not provide the name of the insurance agent.
88. Policy Number
89. Expiration Date
91. I am not required to have workers' compensation liability coverage because:

    1. I have no employees.
    2. I am self-insured (include permit to self-insure below).
    3. I have no employees who are covered by the workers' compensation law (these include: Spouse, Parents, Children, and certain farm employees).
93. Upload a certificate of insurance or permit to self-insure.
95. I certify that I have provided proof of coverage or I am not required to have workers' compensation liability coverage.*

    1. I agree.
97. THE MINNESOTA DATA PRACTICES ACT requires that we inform you of your rights about the private data we are requesting on this form. Private data is available to you, but not to the public. We are requesting this data to determine your eligibility for a license from the City of Edina. Providing the data may disclose information that could cause your application to be denied. You are not legally required to provide the data, however, refusing to supply the data may cause your license to not be processed. Under M.S. 270.72, the City of Edina is required to provide the Minnesota Department of Revenue your MN Tax ID Number and Social Security Number. This information may be used to deny the issuance, renewal or transfer of your license if you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest. The Department of Revenue may supply information with the Internal Revenue Service. In addition, this data can be shared by Edina City Staff, the State of Minnesota Driver License Section, Hennepin County Auditor, Bureau of Criminal Apprehension, Hennepin County Warrant Office and Ramsey County Warrant Office. By agreeing below, you indicate that you understand these rights.*

    1. I agree.
Leave This Blank:


98. Calculate Totals Proceed to Checkout

* indicates a required field