Electronics Pickup Request Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

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

Pickup Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Preferred Pickup Date

Date

Preferred Pickup Time Window

Type of Location

Other

Access or Parking Instructions

Laptop

Any brand or model of laptop.

FreeQuantity

Desktop Computer

Tower or all-in-one desktop computers.

FreeQuantity

Monitor

LCD or LED monitors of any size.

FreeQuantity

Printer

Inkjet, laser, or multi-function printers.

FreeQuantity

Tablet

Any brand or model of tablet device.

FreeQuantity

Smartphone

Any brand or model of smartphone.

FreeQuantity

Other Electronic Device

Please specify in special instructions.

FreeQuantity

Total

Special Instructions (optional)

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