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2. Cigarette Waste Receptacle Application

4. This opportunity is open to all businesses in Norfolk with the ability to install, monitor, and maintain a cigarette waste receptacle at their establishment. Receptacles may be used for customers and/or staff. Businesses will assume the following responsibilities:

   • Pick up your receptacle from Keep Norfolk Beautiful, and install it within 14 days.
   • Anchor the receptacle in place or weigh it down with sand.
   • Monitor the receptacle to ensure the lid stays secure.
   • Empty the receptacle on a regular basis to prevent the receptacle from becoming overfull.
6. First Name*
7. Last Name*
9. Contact E-mail*
10. Contact Phone*
12. Business Name*
14. Address1
16. City
17. Zip
19. Business Type (Select all that apply) *

    1. Retail
    2. Food Services

    1. Services
    2. Other
20. If other, please specify:
22. Number of Employees*
23. Number of receptacles requesting*
25. Property Manager (if applicable)
26. Last Name
28. Describe how the cigarette waste receptacles will be used at your establishment. Please include, at a minimum, the following information: Where will the units be installed? What is the primary use of the area and how heavily is it used? Do you currently have a problem with cigarette litter in that area? Is the area adjacent to a waterway? *
30. Receptacle Location*

    Where will your receptacle be placed? 

31. Who will primarily use the receptacle? *

    1. Staff
    2. Customer

    1. Both
33. Please detail your plan for maintaining the cigarette waste receptacles. Include who will be responsible for monitoring and emptying the units and how often it will be serviced.*
35. How did you hear about this giveaway? *
37. Signature*
38. Date*
    Date

    Date
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

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