DATA SECURITY AND COMPLIANCE
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ENVIRONMENTALLY RESPONSIBLE RECYCLING
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Contact Information
*Required		 Pickup Location
*Required
Company Name*:
Contact Name*:
Phone*:
E-mail Address*:
Address:
City:
State or Province:
Zip or Postal Code:
Requested Pickup Date (mm/dd/yyyy):
 
Asset Details Location Details
Total # of Units:

Type of Equipment:

Number of Each:
 Desktop PCs (approx 35 lbs. each)

 Desktop Laptops (approx 12 lbs. each)

 CRT Monitors (approx 40 lbs. each)

 LCD Monitors (approx 15 lbs. each)

 Servers (approx 50 lbs. each)

 Hard Drives for Destruction

 Hard Drives for DoD Wipe

 Tapes or other Media for Destruction

 Disk Array (approx 35 lbs. each)

 Telephones

 PBX/KSU units (describe below)

 Copiers

 Printers, Scanners, Fax Machines

 Other (provide description below)

 Where is the equipment located in the building?
(i.e. single location or multiple floor, room, etc.)
Will we need a Certificate of Insurance to enter the facility?
No    Yes
Is there an elevator available?
No    Yes
Maximum size truck location can accommodate:
24'    45'    53'
Does the location have a dock?:
No    Yes
Dock Hours of Operation:
Scheduling a specific pickup time required?
No    Yes
Is a lift gate needed?
No    Yes
Is equipment packaged and ready for transport?
No    Yes
Will you require packaging services?
No    Yes
Can hand carts be utilized to transport items from within building to dock/truck?
No    Yes
Where is the palletizing/shrink-wrapping to be done?
(e.g. dock, parking lot)

Questions/Comments:
Security Code:
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