PICK UP REQUEST PICK UP IDENTIFICATION AND CONTACTS Collection point: Date: Adress: ZIP Code: VAT: Member-Ref: Contact name: Phone Number: E-mail: Mobile Phone: COLLECTION POINT DESCRIPTION AND CHARACTERISTICS Preferential pick up dates and times: Access description: On-site loading means yesno If yes, please indicate which: WASTE TO COLLECT - DEPOSITRÃO DEPOSITRÃO or other complete container yesno QUANTITY, TYPE AND EQUIPMENT PACKAGING Cooling Appliances Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Estimated Weight (Kg) Air Conditioning Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Estimated Weight (Kg) Cathodic Ray Tube Tvs Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Estimated Weight (Kg) Flat Pannels Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Estimated Weight (Kg) LED Lamps Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Depositrão for Lamps (QUANT.) Estimated Weight (Kg) Fluorescent Lamps Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Depositrão for Lamps (QUANT.) Estimated Weight (Kg) Other Lamps Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Depositrão for Lamps (QUANT.) Estimated Weight (Kg) Large Household Appliances Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Estimated Weight (Kg) Photovoltaic Panels Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Estimated Weight (Kg) Small Aplliances Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Estimated Weight (Kg) IT Equipment Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Estimated Weight (Kg) IT Consumables Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Estimated Weight (Kg) Portable Batteries Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Depositrão for Batteries/Bring Batteries (QUANT.) Estimated Weight (Kg) Industrial Batteries Bulk items (QUANT.) Palets (QUANT.) Box(es) (QUANT.) Container(s) (QUANT.) Depositrão for Batteries/Bring Batteries (QUANT.) Estimated Weight (Kg) CERTIFICATION OF DESTRUCTION? YESNO IF YES, PLEASE FULFILL THE INFORMATION BELOW: COMPANY NAME: SENDING ADDRESS: OTHER COMMENTS Comments: To submit the form please confirm that you have learnt about the privacy policies. I have learnt about the Pivacy Policy and the Notice of Treatment of Equipment with Personal Data. Privacy Policy Data Containing Devices Privacy Statement
