License Application

Company Information Company Name*

Title*

First Name*

Last Name*

Email*

Phone*

Website

Are you a tax exempt organization?* Yes No Street Address*

City*

Region* Postal Code*

Country*

Facility Information How many processing facilities does your company have today?*

Are any facilities certified?* Yes No

Facilities

New Facility

Site or Facility Name*

Facility Contact

First Name*

Last Name*

Email*

Phone*

Address Street Address*

City*

Region* Postal Code*

Country*

Facility Details

Type of Facility*

Recycler

Refurbisher

Reseller

Other

Services Offered*

Other

Customer Types*

Other

Geographic Scope*

Local

Regional

National

Global

Other

Accepted Materials and Equipment*

Other