Onboarding Form Recycling

1
Please select if you're a new or existing client* This field is required.Required *
Please Select
Please Select
New Customer
Existing Customer (Renewal)
Returning Customer
2
Business Name
3
Contact Name* This field is required.Please type the name of the primary point of contact or account holder.
Mr.
Mr.
Mrs.
Prefix
First Name
Last Name
4
Primary Email Address* This field is required.This is the email we will use to send you updates on your account or service pickup reminders.
example@example.com
5
Primary Phone Number* This field is required.We'll use this to reach out for account/service issues or updates.
Please enter a valid phone number.
6
Preferred Mode of ContactPlease let us know how you prefer to be contacted
Phone Call
Text Message
E-Mail
FB-Messenger
7
Pickup/Service Address Address where the material will be picked up or what will be the return address on the mail in label
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Would you like to add an additional location? * This field is required.Please select yes if you have several business locations and want pickup from each.
YESNO
9
Please type any additional addresses you would like serviced.
Huge
Large
Normal
Small
Ok
Ok
10
What service are you requesting?* This field is required.Select the service you have or would like (you may select multiple)
Please Select
Gloves & PPE
Table/Bed/Chair covers, sheets and or protectors
Other
11
What would you be Recycling?* This field is required.We do not pick up sharps due to legal restrictions..
Gloves & Glove Boxes
Aprons / Over Body Suits (Non-Soiled)
Other Latex, PVC, Vynil Material
Tubes, Tips & Grips
Chair/Table/Bed Covers
Other
12
How often would you like us to pickup your materials?* This field is required.If you want a custom pick up, select other.
Weekly
Bi-Weekly
Monthly
Bi Monthly
Other
13
If other, Please Specify
14
What Day of the week would you prefer the pickup on?* This field is required.Mon - Sun (please note we may not always be able to pickup during business hours but will pickup by end of day)
Please type above
15
What Supplies would you need?* This field is required.All supplies are free of charge, please note that the large rollaway locking bin will cost a one time fee of $30. If you are only doing gloves and other ppe (depending on how large volume you produce) a large trash bag works just fine.
3-6 Gallon Bags (Good for Workstation Bins)
13-20 Gallon Bags (Good for End-of-Day Collection from multiple stations)
33-45 Gallon Bags (Ideal if the shop combines gloves from all artists into one main bin for daily or weekly collection)
Small Bins (3-6 Gallon)
Med Bins (13-20 Gallon)
Large Bins (33-45 Gallon)
X-Large (50-75 Gallon > Outdoor Roll away) FEE $15
Small Outdoor Bin 25-gal (gray 25gal) FEE$15
USE THIS OPTION IF YOU WILL USE YOUR OWN Bags
USE THIS OPTION IF YOU WILL USE YOUR OWN Bins
Other
16
Where would you like us to pickup the material?* This field is required.We ask that you leave it outside the day of pickup so that we may collect your materials without disturbing you. If you are in a busy area, placing the bag by the dumpster or back door is typically beneficial.
Front of Building
Side of Building
Back of Building
Next to Dumpster
In a pickup container (if provided)
Other *specify on next question*
MAIL-IN Program (IF outside of MO, KS, IA, NE Specified Cities)
Other
17
If other, Please specify belowIf not, please continue.
18
Please describe anything we may have missed or if you would like to add anything If you are requesting bins, bags or supplies please specify below how many of each you will need. Otherwise comment on any questions you have and click next.
Huge
Large
Normal
Small
Ok
Ok
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CONDINSED TERMS AND CONDITIONS

By agreeing to this statement, you are allowing MHSGF LLC Recycling (aka CentralStates Glove Recycling) to access your property solely to pickup material noted above on the day(s) listed and agree to accept services free of charge from MHSGF LLC Recycling. You waive any right to sue MHSGF LLC & it’s personnel for trespassing during conduction of the service(s) being given. If at any time you wish to no longer accept services, you must give a written notice. This also states MHSGF LLC cannot sue or hold liable you (individually, or as a business) for any injury’s occurring on premises during service work.
20
Terms and Conditions* This field is required. Click the hyperlink to view the full Terms & Conditions
21
Signature* This field is required. To verify this is valid submission, please sign below
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