Service Request Form

If you would like to arrange for a pick up at your facility, please fill out the following information. A representative will get back to you to confirm your request.




Company Name:*
First Name:*
Last Name:*


Pickup Information:
Site Phone:*
Site Fax:
Site Contact Email:*
Street Address line 1:
Street Address line 2:
City:
State:
ZIP:
Site Name (if different):


Approximate Total Number of Units:
          TV/Monitors:
          Desktop Computers:
          Notebooks:
          Printers/Copiers:
          Other (please specify):
          


Type of Service:
     Asset Recovery (potential remarket value)
     Recycling Services (no remarket value)
 
Requested pickupMonth   Day 

Year 
 
Equipment Location:
Equipment Floor:
Equipment Condition:
 
Do you have an elevator on site?
     Yes
     No
Do you have a forklift on site?
     Yes
     No
If you did not mark loading dock above, do you have one on site?
     Yes
     No
 
Any additional information you would like to provide?

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