City of Dacono Refuse Haulers' License Application

2. Is this a NEW application? *

   1. YES

   1. NO

4. Description of business operations*

   Please be as detailed as possible.

6. Name of Company *

7. Address1*

8. City*

10. State*

11. Zip*

12. Phone Number*

14. Email Address*

15. Federal Tax ID:*

16. Colorado State Sales Tax #

    (If applicable)

18. Business Owner's Name*

19. Address, City, State, Zip*

21. Upload Certificate of Insurance*

22. Upload scanned version of paper bond*

    A surety bond in the amount of $2,000 is required for this application. Please mail original copy to the City of Dacono, PO Box 186, Dacono, CO 80514

24. I swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one):*

    1. I am a United States citizen
    2. I am a permanent Resident of the United States
    3. I am lawfully present in the United States pursuant to Federal law
26. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. If further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18- 8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.

    I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. If further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18- 8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.

28. Please read the following statement:
    I declare, under penalty of perjury, that this application has been examined by me and that the statements made herein are to the best of my knowledge and belief, true, correct and complete.

    I declare, under penalty of perjury, that this application has been examined by me and that the statements made herein are to the best of my knowledge and belief, true, correct and complete.

30. Signature*

31. Date*

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field