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Onsite Pick-Up Request Form
Your Contact Information: (* Items marked with an asterisk are required)
*Your Name (First,Last):
*Your Company/Organization Name:
*Your Email Address:
Pick-Up Information: (* Items marked with an asterisk are required)
Pick-Up # (Optional):
Your P.O.# (If Required):
*Job Site Contact Name (First, Last):
*Job Site Contact Phone:
*Address 1:
Address 2:
*City:
*State:
Choose
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*Zip:
*Is The Material To Be Recycled Palletized?:
Material IS NOT Palletized
Material IS Palletized
*Fork Lift Available?:
Fork Lift IS Available
Fork Lift IS NOT Available
*Loading Dock?:
Location HAS A Loading Dock
Location DOES NOT Have A Loading Dock
Number Of Pallets And/Or Pieces:
NOTE: If none, enter 0
*# Of Non-Palletized Computers/Copiers/Printers:
*# Of Non-Palletized Monitors:
*Number Of Pallets:
*Total # Of Computers/Copiers/Printers:
Include Non-Palletized & In Pallets
*Total # Of Monitors:
Include Non-Palletized & In Pallets
*Total # Of Independent Hard Drives:
*Require Printed Certificate Of Destruction?:
Yes. Please prepare a printed certificate of destruction.
No. We do not require a printed certificate of destruction
Other:
Special Instructions:
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