Houseside Collection Request

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Name & Address

First Name *

Last Name *

Address *

City *

Postal Code *

Contact Information

Phone *

Email *

How did you hear about this program?

Will you be disposing of ewaste such as a computer monitor, printer or fax machine?

Yes

I hereby certify that the material I put in this bin, in fact, originated from a household and not from a business, my own or otherwise. I further certify that all the information provided on this form is accurate to the best of my knowledge. I realize this form may not release me from future liability for the waste and that failure to provide accurate information may result in enforcement action under the authority of any applicable state or federal laws and regulation.
I accept these terms. *

Payment Information

Payment Amount

$25.00
(2.95% convenience fee will be added to your transaction)

Credit Card Type *

Credit Card # *

Please enter your Credit Card Number. Please enter your Credit Card Number.
(No dashes or spaces.)

Expiration * (Month/Year)

CVV Code*

Thanksgiving Holiday Collection Delay