Lithium Battery Disposal Request Form

Lithium Battery Disposal Request Form
Request lithium battery disposal pickup or drop-off. Please complete all fields to help us process your request efficiently.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pickup or Drop-off
Battery Type
Battery Quantity
Battery Condition
Packaging and Safety Status
Pickup Address (if Pickup selected)
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Date and Time
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Special Instructions or Notes
Should be Empty: