Appliance Recycling Request Form
 
To pre-qualify for the appliance recycling service, you must
fill in all of the required fields below. When you're done,
select the Continue button to submit your information.
 
* Indicates required field
Contact/Customer Information
*First Name:
Middle Initial: if applicable
*Last Name:
*Street Address:
*City:
State: ZIP:
*Day Phone:  (ex. 5553191219)
*Home Phone:  (ex. 5553191219)
*E-mail:
Account Number:
Appliance Information
*# of Appliances:  (limit 2)
Appliance #1
*Type:
Brand:
Color:
*Location:
*Primary or Secondary:
*Age:    Years Old
Appliance #2 if applicable
*Type:
Brand:
Color:
*Location:
*Primary or Secondary:
*Age:    Years Old
Helpful Information
To make it easier to find your house.
*How did you hear about the Appliance Turn-In Reward Program?
*Which aspect of the Appliance Turn-In Reward Program
  most influenced your decision to recycle your appliance?
*Are you replacing this appliance with a new model?
*What building type describes your home?
 
Is the appliance in working condition?
Yes     No
Is the appliance regular household size of between 14 - 27 cubic feet?
Yes     No