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Recycling Request Form *Required Fields
*Name:
Title:
*Agency/Organization:
*Address:
*City:
*State:
*Zip:
*Telephone:
Fax:
*E-mail:
Which activities are you interested in? (check all that apply)	Recycling Destruction Other
How soon would you be interested in these activities?
Approximately how many pieces of equipment are, or will be, involved?
What type of equipment are you retiring? (check all that apply)	Laptops Monitors PCs Printers Other
Is the equipment?	Functional Non-Functional
How did you hear about us?
Please add any additional comments that you have concerning your equipment disposal needs.