The 4th BIN

Residential Client Contact Information

Please fill out this form. Once we receive the completed form we will contact you and coordinate a pickup date.

First Name:

Last Name:

E-Mail Address:

Address:

Apt #:

City:

State:

Zip Code:

Phone:

Cell:

Promo Code:

Computers (PC, mac or server):

Laptops (PC or mac):

Flat Screens:

CRT Monitors:

Printers:

Network Equipment:

TVs:

Stereos:

Phones:

Cameras:

Other:

Please enter any details about this Equipment.

Check here if you require Data Erasure.

(Note: Data Erasure is $10.00 per hard drive.)

Is there anyting else we need to know about the equipment and/or building?

For any questions or comments, please contact us at: 646-747-5985 or info@4thbin.com