Residential Keycard Registration Form

Prefer a paper copy?

Residential Keycard Registration Form mailto: Public Works Administrator
1550 West 3rd Street
Williamsport, PA 17701

Registration fee

$10 - $5 There is a $10.00 initial registration fee or a $5.00 renewal fee associated with the Residential Keycard Registration. You will be contacted by a member of the Public Works to determine a method of payment.

Contact Information

First Name *

Last Name *

Address *

City *

State *

Zip *

Home Phone *

Alternate Phone

Email *

Drivers' License Number *

Additional Household Member Information

First Name

Last Name

Address

City

State

Zip

Home Phone

Alternate Phone

Drivers' License Number

Vehicle/Trailer Information

Max 2 vehicles, 1 trailer, must be registered to a listed individual:

Vehicle 1

Make *

Model *

Year *

Tag *

Registered Owner *

Vehicle 2

Make

Model

Year

Tag

Registered Owner

Trailer

Make

Model

Year

Tag

Registered Owner

Compliance Information

I certify that I am the owner/tenant/responsible party of the above-listed property within the City of Williamsport, and I have read the attached rules and regulations and hereby agree to follow all rules and regulations pertaining to the City of Williamsport Brush/Mulch Recycling Collection Area and key card registration. I understand that violation of any of these rules and regulations will result in forfeiture of privileges to use the Brush/Mulch Recycling Collection Area and termination of key card access. I agree to make known to the household member (additional responsible party) listed, the terms and conditions for use of the Brush/Mulch Recycling Collection Area and key card access and agree to take responsibility for their actions while using my key card. Additionally, I acknowledge the above information is true and correct.

Applicant Signature:

Residential Keycard Registration Form