| Image Verification | |
| Submission of Assets for Recycling and or Disposal Connecticut |
| Company Name | |||||
| Your Name | |||||
| Your Address | |||||
| Your City | |||||
| Your State | |||||
| Your Zip Code | |||||
| Your Phone Number | |||||
| Your Email | |||||
| Description of Services Desired | |||||
| Number of Monitors | |||||
| Number of PC's | |||||
| Number of Laptops | |||||
| Misc. IT Equipment | |||||
| Attach File with Inventory for Recycling | |||||
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