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Customer Information
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| Company
Name: |
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Contact
Person: |
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| Physical
Address: |
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Mailing
Address (If different than physical): |
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| City: |
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State: |
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| Zip
Code: |
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Email
Address: |
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| Telephone: |
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Fax: |
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Computers, Peripherals,
and CRT's
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| Description |
Quantity
|
Description |
Quantity
|
| Monitors
up to 17": |
|
Monitors
over 17": |
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| Televisions
- Non Console: |
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Television
Consoles: |
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| Computers
and Laptops: |
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Other
(Keyboards, mice, speakers, etc.): |
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| Desktop
Printing and Imaging (under 100lbs.) - Including printers, faxes,
scanners, etc.: |
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Floor
Copiers and Printers (over 100lbs.): |
|
|
Description
|
Quantity
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| UPS's
(Battery Backup Systems) |
|
|
Lighting
|
| Description |
Quantity |
Description |
Quantity |
| 4`
Straight Fluorescents (Uncoated): |
|
8`
Straight Fluorescents (Uncoated): |
|
| Other
Straight Fluorescents (Uncoated (Please put quantity in feet)): |
|
Straight
Fluorescents (Coated) Please put quantity in feet: |
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| U-Lamps,
Circles, and Compact Fluorescents: |
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HID
Lamps, Sodium, and Mercury Vapor: |
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Batteries
|
| Description |
Quantity |
Description |
Quantity |
| NiCD,
NiMH, Alkaline(0% Mercury), Zinc Carbon, and Carbon Air: |
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Nickel
Zinc and Lithium Ion: |
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| Button
Cells: |
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Lead
Acid (all types): |
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| Alkaline
with Mercury: |
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Zinc
Air, Mercury, and Carbon with Mercury: |
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Ballasts,
Transformers and Capacitors
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| Description |
Quantity |
Description |
Quantity |
|
PCB, DEHP,
Magnetic, and Electronic Ballasts:
|
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Transformers:
|
|
| Description |
Quantity |
| Large
and Small Capacitors: |
|
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Mercury
Related Items
|
| Description |
Quantity |
| Devices
Containing Mercury: |
|
|
Request
|
| Do
you want a quote: |
|
| Timeline
of Pickup: |
|