Please provide the following contact information:

First Name
Last Name
Title	(optional)
Company	(optional)
Address
City
State	Select Please AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
Zip Code
	Select Please YES NO Is this a residential address?
Phone	xxx-xxx-xxxx
Extension
E-mail   Retype E-mail	(a valid e-mail address is required to process your request)
	Select Please Pink Postcard Previous Experience Google Yahoo Ask Jeeves Friend or Relative Radio or Article Mailing Other Please tell us how you heard about us.   If "Other" please explain

Please give us the manufacturer & model of each laptop.

(separated by commas)

example -  DELL Latitude 8200, Compaq Presario 4260

 

My laptop is a Pentium I or higher or equivalent           Select one NO YES

My laptop works and has all its components attached  Select one NO YES

My laptop includes the power cord and battery             Select one NO YES

 

 

RFBC absorbs all of the costs for this program. Please be respectful of the time, effort and money it takes to process & fill your request. Make certain any questions you may have are addressed prior to submitting your request.

 

Please double check all your information, including phone and email address for accuracy. If your information is not correct we may not be able to fulfill your request.

 

All information submitted is for the sole purpose of the Recycle for Breast Cancer program and will not be sold or distributed to any other individuals or organizations.