Nationwide Waste Service | Porta Potty Rental | Coast to Coast Waste Service Professionals

Name of Person Placing Order*

First Last

Phone Number of Person Placing Order*

Name on CC*

First Last

Has Authorization To Use CC*

Yes
No (if no then stop and do not move forward)

Phone of CC Holder*

Email*

CC#*

CC Exp Date*

Delivery Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Amount Authorized*

Products Ordered*

Delivery Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name of on site contact.*

On site contact phone number.*

If unit will be placed behind a locked area, please provide code for entrance.

Location Type.

Residence, Park, Construction Site, Business, ect...

Event/Construction Type.*

Birthday, Wedding, Commercial Remodel, Residential Remodel, ect...

Where to place the equipment.*

Units must be placed within 15 feet of driveway. Driver will used discretion to accommodate your request.

Event/Project Start Date*

Please provide the date in which the units will first be used.

Event/Project End Date*

Please provide the date in which the units will last be used.

Delivery Date Requested.*

We will do our best to accommodate the date you select, however 48 hour notice is needed to ensure date selection. If you need service sooner than this, please be sure to call our office and speak with one of our helpful customer service representatives.

Pick Up Date Requested. **

Monday - Friday Availability. **Construction Rentals orders are charged on a rolling 28-day OPEN billing cycle, which is billed out and drafted in advance. The customer must call our corporate office at (855) 301-2530 to have the unit removed a minimum of two business days prior to the start of the next 28-day cycle to avoid any additional charges.

Disclosures Advised*

Order is nonrefundable once booked.
We do not prorate.
Long Term recurring orders must be called in to our phone number (855) 301-2530 2 or more business days prior to the end of your current billing cycle to arrange your pick up date and to stop further billing.
Once delivered, you are responsible for the unit(s) if damaged or stolen.

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New Order Form

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