We will contact you within 2 business days after receiving this submission. Thank you.

Request Date:


Company Name:


Contact Name:


Pickup Location:


Street Address:


City:

Zip:


Business Phone: ext:

Business FAX:

Cross Street:

Pickup Hours:Pickup Days:

Parking Restrictions: None Special Instructions Loading Dock? No Yes

Special Instructions - (If any)


Please list computers, monitors, printers, parts and accessories below:
example: [Qty] 9, Wizbang / Plethyum, [MHz] 333, [RAM] 64 megs, [HDD] 2 gig, c, [mon]15", [pri] laserjet4. Qty Make / Model MHz (speed) RAM (memory) HDD size laptop=L midtower=MT desktop=D monitor size printer: Lazer=Laz Inkjet=Ink DotMatrix=Dot

Please list computer parts and accessories below

*First Name:

*Last Name:

*Primary Phone

Mobile Phone

*Email:

*WHEN would you like to be contacted?
Morning Afternoon Evening

*HOW would you like to be contacted?
Telephone Email

*How did you hear about eWaste Corporation? Radio Television Internet Corporate Referall

*Please enter your request to the eWaste Corporate Office.