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E-waste Pick-up form
Civicorps
>
E-waste Pick-up form
E-waste Pick-up Request Form
Date of Request
Requested by
First Name
Last Name
Company
Are you a current client?
Yes
No
Street Address
City
State
Zip
Requester Email
Requester Phone
Site Information
Contact on the day of pickup
First Name
Last Name
Pickup Location Address
Street Address
City
State
Zip
Hours of Operation
Are you closed for lunch?
Yes
No
Where are Items Located?
Office
Dock
Warehouse
Will we need the following?
Stairs
Elevator
Freight Elevator
Items are: (please choose all that apply)
Palletized
On pallets only
Boxed
Loose material
Will we require
Prior security clearance
Additional helper
Do you have a designated loading area?
Yes
No
Is insurance required for pickup?
Yes
No
Location of designated parking area
E-Waste Information
Number of Items
1-5
6-10
11-15
16-20
>20
Quantity if Greater Than 20
Enter in the number of electronics.
Note: We accept all computer-related cables of any quantity. No techno trash: CDs DVDs and manuals. No stand-alone speakers.
Laptops
Laptop Carts
CRT/Television
LCD/LED Monitor
LCD/Plasma TV
Computer CPU (tower)
Cell Phones
Copiers
Fax Machines
Hard Drive
Keyboards/Mice
Microwaves
Printers/Scanners
Servers
Tablets/E-Readers
Telephone Systems
Other electronics or small appliances