Request-A-Pickup Form

Please complete this form to have Assured ITD provide on-site pickup of your end-of-life computers and electronics. Once your request is received, Peter Graber, Executive Manager, will follow up with you to schedule an appropriate time.

Pickup Request Form
1)  Enter Contact Information
* Company/Organization
* Your Name
* Your Email
* Street Address
 
* City
* State
* Zip Code
* Telephone
   Facsimile
* Organization Type



 Corporate / Commercial
Government / Not-for-Profit
Residential Consumer
Select Industry Segment
2)  Select Project Service Requirements
Will you require a Certificate of Destruction? Yes   No
Will you require on-site hard drive destruction? Yes   No
3)  Describe Project Materials/Facility
Enter the total estimated weight of the material? lbs. Weight Estimator
Is the material located in a centralized place or does
it need to be gathered up by Assured ITD staff? Centralized for easy pickup  
Needs to be gathered up
Does your facility have a loading dock? Yes   No   N/A
Can the equipment be removed with a hand cart
or will it require more the one person? One person can move all materials  
Multiple people will be needed
4)  Payment Information
Please select how you will pay






 Cash or Check  
Credit Card  
Invoice
Notes/Comments
     



For questions about Assured™ ITD and our services, please contact Peter Graber at (919) 215-3165 or via email at pgraber@assureditd.com