Pick-up form — Green PC

Contact Name *

Contact Name

First Name

Last Name

Residential or Non Residential Pickup? *

For residential pick-up there is a $65 cash only fee

Yes, I am aware of the $65 cash only fee

I am not scheduling a Residential pick up

Contact Phone Number *

Contact Phone Number

(###)

###

####

Contact Email Address

Name of your company (if applicable)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Requested Pick-Up Date *

Requested Pick-Up Date

YYYY

Requested Pick-Up Time *

Requested Pick-Up Time

Hour

Minute

Second

Items you are recycling?

Are we picking up loose items or pallets?

How many loose items/pallets?

Comments and Special Instructions

Should We Bring Extra Totes/Gaylords?