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:	1-15 16-30 31-100 101-200 >200

          Desktop Computers:

1-15 16-30 31-100 101-200 >200

Notebooks:

1-15 16-30 31-100 101-200 >200

Printers/Copiers:

1-15 16-30 31-100 101-200 >200

Other (please specify):

1-15 16-30 31-100 101-200 >200

Type of Service:     Asset Recovery (potential remarket value)

     Recycling Services (no remarket value) Requested pickupMonth

January February March April May June July August September October November December

Day

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year

2010 2011 2012 2013 2014 2015

 

Equipment Location:

Loading Dock one location Loading Dock various locations Inside Warehouse one location Inside Warehouse various locations Inside Building one location Inside Building various locations

Equipment Floor:

1

^st

Floor 2

^nd

Floor Highest Floor

Equipment Condition:

Boxed Palletized Loose

Do you have an elevator on site?     Yes     No

 

Do you have a forklift on site?     Yes     NoIf 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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