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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:
*Zip:
*Is The Material To Be Recycled Palletized?:
*Fork Lift Available?:
*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?:
Other:
Special Instructions:
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