Pickup Request

Please complete the form below to receive a quote from RLGA.

All fields and sections are required unless they are noted as optional.

Requestor Information

Company Name

Contact Name

Address Line1

Address Line2

City

State

Zip Code

Phone Number

Pickup Location Information #1

Company Name

Contact Name

Address Line1

Address Line2

City

State

Zip Code

Phone Number

Equipments

Have Forklift

Yes No

Have Loading Dock

Yes No

Have Pallet Jack

Yes No

Truck Restrictions

Driver Instructions

Special Handling

Palletize and Shrink Wrap

Yes No

Certificate of Destruction

Yes No

Record Serial Number(s)

Yes No

Data Wiping

Yes No

Total Weight(lb)

Total Pallets

Additional Instructions