E-waste Pick-up Request Form - Civicorps Recycling

Requested by:*

First Last

Date of Request*

Company

Are you a current client?

Yes
No

Address*

Street Address Address Line 2 City State ZIP Code

Requester's Phone

Requester's Email Address*

Site Information

Name of contact on the day of pickup*

First Last

Contact Phone*

Pickup Location Address*

Street Address Address Line 2 City State ZIP Code

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

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

CRT/Television

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

Name

This field is for validation purposes and should be left unchanged.