Electronics Recycling-by Appointment Only

Are your items placed at the Curb?:(*)

Yes No

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If not at curb, location of items (driveway, sidewalk, front porch, etc):

Location of items?

Do you have a written handicap agreement with the town?:(*)

Yes No

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Street/house Number:(*)

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What is the exact Street Name of repair? (*)

Please choose one

If street name is not listed, what is it?:

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Type of Items: check all that apply(*)

Any other comments?

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Name of person reporting:(*)

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Telephone number:(*)

Please enter your telephone number where we can reach you

E-mail address:(*)

please enter a correct email address.

(*)

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