1. Site Name

2. Account Number

3. Other Site Name (Unit/Department)

(if applicable)

4. PO/Cost Center Number

(if applicable)

5. Scheduling Contact Name

(if applicable)

6. Scheduling Contact Phone

(if applicable)

7. Scheduling Contact Email

8. Address

(if applicable)

9. Storage Address

(if different)

10. Number of Items

11. Name of the Items (Mattress, Sofa, Wheelchair, Soft Plastic, etc.)

12. Where Are the Item(s) Located (Direct Pickup From Your Unit Is Available at No Extra Charge)

(if applicable)

13. Stairs or Elevators

(if necessary)

14. Business Hours, Including Weekends

(if applicable)

Psst… Already used our pickup service?

Click Here to provide your feedback.