Certified Electronics Reuse & Recycling Service Request

Certified Electronics Reuse & Recycling Service Request

All solutions providers are either e-Stewards and/or R2v3 Certified
General Information
Job Type*
Job Requester Name*

First NameLast Name
Job Requester Email*
example@example.com
Client*
Date Submitted*

MonthDayYear
Date
Job Reference Number*
Unique Number
Preferred Pickup Date

MonthDayYear
Date
Pickup Date (Range)*
MM/DD to MM/DD
Documentation Needed*
Pickup Location, Contact, and Instructions
Company/Organization*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Person*
Name or Company/Organization Contact
Contact Person Phone*
Please enter a valid phone number.
Contact Person Email
example@example.com
Description of Equipment to be Collected*
Descriptions/Quantities/Notes/etc.
Equipment Needed*

Moving DollyPallete JackBoxes/GaylordsLiftgateShrink-Wrap
Palettes Needed (Qty.)*
Estimated
Pickup Instructions*
Loading Dock (Yes/No)*

YesNo
Site Up Multiple Floors*

YesNo
Is an Elevator Available*

YesNo
Images & Files
Upload Digital Assets

File Types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Should be Empty:

General Information