Form Center

2. *Please note :  Submitting this application does not guarantee approval. Before the waste container is placed, the Street Commissioner must review your request. If the request is approved, they will respond with a signed approval document.

4. Date*
   Date
6. Location where Waste Container is to be Placed*
8. Start Date*
   Start Date
9. End Date*
   End Date
11. Reason for Placing Container at this Location*

13. I agree to place lights on or around the waste container for public safety and agree that I will not allow debris to accumulate around the waste container.

    I further agree that on behalf of myself, my executors, administrators, heirs, and next of kin, or if I am making this request on behalf of a business or corporation, its officers, directors, and stockholders, and any successors and assigns of the aforementioned, I HEREBY WAIVE, RELEASE AND DISCHARGE from any and all claims or liabilities for death, personal injury, property damage, theft or damages of any kind, which arise out of my use and/or placement of the waste container at the above described location, the City of Bluffton, the Mayor of Bluffton, the Common Council of the City of Bluffton, and any agents, successors, assigns or employees of any of the foregoing. I HEREBY AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims or liabilities that I have waived, released or discharged herein. I HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS any person or entity mentioned above from any claims made or liabilities assessed against them as the results of my use and/or placement of the dumpster.

15. Confirmation of Authorization*

    1. I hereby affirm that I am eighteen (18) years of age or older and am authorized to execute this permit request, and that I have read this document and understand it contents.
17. Name of Organization / Business*
18. Requestor's Name*
20. Phone Number*
21. Email*
23. Electronic Signature*
25. Information Consent*

    1. I consent to the City of Bluffton, Indiana storing my submitted information so they can respond to my inquiry.

27. *Reminder :  Submitting this application does not guarantee approval. The Street Commissioner will review the application and respond in a timely manner.

    If you have any additional questions, you may contact Tim Simpson at 260-824-0714.

Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field