Battery Donation Drop-Off Form

Donor Full Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Mailing Address (optional)

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Date and Time of Drop-Off

Date

Hour MinutesAM/PM Option

Type(s) of Batteries Donated

Approximate Number of Batteries Donated

Are the batteries securely packaged for safe transport?

Would you like to receive updates about future recycling events?

Additional Comments or Special Instructions

Signature (please sign to confirm your donation and acknowledgment)