172-26 Attachment.pdf

TOWNSHIP OF WEST ORANGE OG MAINSTREST, WEST ORANGE, Nod, 020382 ADMINISTRATION AND FINANCE ROBERT fs, PARIST . Pots (OF) 3254070 Mayor Pere (973) 736-9182 Hennail; JGross@wostornnge.acg JOBING, GROBB, MERA, CMO. _ WW. Wwebtonunge.arg Director-of Finanes uO . Chief Financia Gificer _APPLIDATTON Fl NEIWBURSUMENT FOR GARBAGE AND narUse COLLECTION CONTS HOREUANT TO CHAPPR 1 OF THI REVISED BENERAL ORDINANCES OF THE TOWNSHIP OF WEST ORANGE APLEASE TYPE GR PRINT a. vans Boe? Bol Main Te ene. 2, Texepone NuMpER:. F722, 3S Of an a. steer apres: 20e-3O% May Sh luesk Oraesa NT ozs? 4, mock (ML! on Lol ror which aeimURSEMENTIS SOUGHT)” , a “Nae RF vasocuaTION oR Se Spe 306 fsa, 2 bbe. ar ; s ay . _ % eeuraurust ontsetion costo 2 {150 8 (180. ___WeEkly, MoNTAR vag 22D. SERVICE RAY MBRITS MADE BY. | LINGIVIDUAL, (4 ANBOGIATION harher isoatatey Ug, Ca. 11. TOTALAMOUNT OFReMounseWenr sougHn.. & L/SSe 7 Ja. PERIOD ROR WHICH REIBMURSEMENT (6 BOUGHT: pone ox - Dye. Doak . 4d, RNELOSI'COPIRS OIF ALL BILLS FOS WHICH ABIMSUREEMENTS SOUGHT. PLEASE SHOW NUMMBRR GF WRHTS BEING COLLECTED Ron AAgH PERE 14, COPY OD SINVREL AGREEMENT OR CONTACT, * ROPECANTS CERTIFICATION oartly tont the Toraiming statarnents and information are tue Us the haat of ny kopwledge ond belieh | arawarethaet fa any of fhe far rggatng te willfully falaa, 1 ent subjedt-ty punlshment Lal Gee Ges ames, Peed bl aernate . Brly-2b PLEASE RETURN APPLICATIONANS COPIES OF wus TO: JOH O. GROSS. CHO FINANCIAL OFFIGER FOWANSHIP OF WEST CHANGE 66.)AAIN STREET ‘West ORANGE, NI 07082: (ReLOW FOR GEMcIAL bse ONLY APPROVAL: -Clilet Bnandial Oftiser