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

    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