Corporate Customer Request Form


Customer Name
 
Address
 
Address2
 

City   State    Zip  
Phone
 
eMail
 
Contact Name
 
Please Describe Your Electronics Waste (please include types of
e-waste, quantity and size if possible):
 
Do your require transportation and/or labor?
If So, Please Describe.
    
Annual Volume In lbs:      Shipping Frequency:
Do you have a loading dock? Yes
Do you have a fork lift? Yes
Pickup Location Name
 
Pickup Location Address
 
Pickup Location Address 2
 
Pickup
City  State    Zip 
Pickup Phone
 
Pickup Contact Name
 
How will material be packaged upon pickup?
Boxes
Pallets
Don't Know
Other
Other Description