Battery Recycling Licensing Form

Battery Recycling Licensing Form
Please complete the form to apply for a battery recycling license.
Applicant Full Name
First NameLast Name
Company Name
Company Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Type of Batteries to Recycle
Number of Batteries to Recycle Monthly
Should be Empty: