IT/E-Waste Disposal Site Information Pickup Form

Organization Name*

Hours of Operation*

Data Wipe Services*

Equipment Pickup Street Address*

City*

State*

Zip code*

Estimated number of pieces to be picked up

(In order to recieve a proper logistics quotation, it would be helpful to have an approximate breakdown)

CPUs

Laptops/Tablets

Servers

Desktop Printers

Cell Phones

Floor Printers / Copiers

15” LCD Monitors

17” LCD Monitors

19” LCD Monitors

20”+ LCD Monitors

15” CRT Monitors

17” CRT Monitors

19” CRT Monitors

20”+ CRT Monitors

Devices over 100+ lbs

Please list details in "Other" below

Yes

Data Wiping Services:*

NIST 800-88 Data Wiping/Destruction Services (please check box): Please select (if none selected - Data Wipe Service is declined)

Depot Data Wipe
Onsite Data Wipe
Depot Shred
Onsite Shred
No Data Destruction Services Required*

* If data wiping services are declined, customer shall indemnify and hold harmless AnythingIT, LLC.

Other (Need full description i.e. type, approximate weight & dimensions)

What floor of the building is equipment located?

Is there a limitation on the size truck to come onsite?

If yes, place Maximum Size

Will you require assistance with onsite packaging?

Will you require assistance with onsite packaging? If no, please be advised equipment must be packaged on pallets and shrinkwrapped

Yes
No

Can equipment be de-installed and put into a central location for packing & pickup?

Yes
No

Is there room onsite to shrink-wrap and palletize?

Yes
No

Does the facility have a loading dock?

Yes
No

Does the facility have a freight elevator?

Yes
No

Do you have a pallet jack or forklift at your location?

Yes
No

Does the facility have a public elevator?

Yes
No

Work to be done durning normal business hours (Mon-Fri / 9am-5pm)

Yes
No

Will a property pass be required to remove equipment?

Yes
No

Do we need to schedule time to use the loading area?

Yes
No

Are there any specific security issues with gaining access to your facility?

Yes
No

Does your facility require a Union laborer to provide onsite services?

Yes
No

Primary Contact Name*

Phone Number*

Email Address*

Secondary Contact Name

Phone Number

Email Address

Additional Information or Notes

BE ADVISED: A separate form MUST be completed for each location. Pickup dates may be requested but are not guaranteed. For all media where data destruction services are declined, customer shall indemnify and hold harmless AnythingIT, LLC.
Please direct any questions to sales@anythingit.com

PLEASE NOTE: Any major inaccuracies of information submitted may cause service delays or increased cost.

Thank you for your assistance in providing the above information.

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IT/E-Waste Disposal Site Information Pickup Form

Estimated number of pieces to be picked up

Company

Programs & Services

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