Form NJ - SimplyCans

Service Request Form

Step 1 of 5 – Service location

Service location

We currently only service specific ZIP codes in New York and New Jersey. If your ZIP code is not accepted, we are not in your area yet.

Select your state *

Service ZIP code *

Plan & pricing

One-time

$36.99 / can

Monthly

Up to 2 cans – $16.99 / can
3+ cans – $14.99 / can

Quarterly / Bi-Monthly

Up to 2 cans – $21.99 / can
3+ cans – $19.99 / can

Plan *

Number of cans *

Total price (USD)

$0.00

Garbage collection schedule

What day(s) is your garbage collection? *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Time of garbage pick-up (24h format) *

Overnight Pickup 06:00 - 08:00 08:00 - 10:00 10:00 - 12:00 12:00 - 14:00 14:00 - 16:00 16:00 - 18:00 Other

Notes

Your information

First name *

Last name *

Email *

Phone *

Street address *

Street address 2 (optional)

City *

State *

ZIP code *

Payment details

Credit card

Visa, Mastercard, Amex, Discover

Card type *

Card number *

Cardholder name *

Expiration (MM/YY) *

CVV *

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