Batteries Form

2. Date*
3. Company Name*
5. Type of Business*
6. Contact Name*
8. Address*
9. City*
11. Zip*
12. Phone*
14. Contact E-mail*
16. Invoice E-mail
18. Choose One

    1. Business
    2. Non Profit
20. Business Tax ID Number or RCRA Generator Status
22. Alkaline (total weight in lbs.):
24. Rechargeable Ni-CD , Ni-HM (total weight in lbs.):
26. Lithium (Li) (total weight in lbs.):
28. Lithium Ion (Li-ON) (total weight in lbs.):
30. Battery Backups (total weight in lbs.):
32. Other (please specify - total weight in lbs.):
34. Notes:
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field